Here's How to Treat Childhood Apraxia of Speech [3 ed.] 1635502837, 9781635502831

Citation preview

New to the Third Edition: • Updates to reflect the current research findings related to the genetic and neurogenic correlates of CAS, as well as the features of CAS that are most sensitive and specific to consider when making a differential diagnosis • New chapters on unique needs of children with co-occurring challenges, such as ADHD, dysarthria, and developmental coordination disorder, and treatment of CAS via telepractice

Margaret Fish, MS, CCC-SLP, is a speech-language pathologist working in private practice in Northbrook, Illinois. She has 40 years of clinical experience working with children with severe speech-sound disorders, language impairments, and social language challenges. Margaret’s primary professional interest is in the evaluation and treatment of children with childhood apraxia of speech (CAS), and she presents workshops on topics related to CAS across the world. Her workshops and writing focus on providing practical, evidence-based evaluation and treatment ideas to support children with CAS. Margaret serves on the Professional Advisory Council for Apraxia-Kids.

Amy Skinder-Meredith, PhD, CCC-SLP, is a Clinical Professor at the Elson S. Floyd College of Medicine at Washington State University-Spokane, where she is the founder and director of Camp Candoo, an intensive summer program for children with CAS. She has been an SLP for over 30 years and has worked in the public schools, hospitals, university clinics, and private practice settings. She has published and presented her research on CAS at national conferences, has given over 100 workshops for practicing speech-language pathologists across the U.S. and internationally on assessment and treatment of CAS, and is on the Professional Advisory Council for Apraxia-Kids. She enjoys the continuous learning that comes with working with kids with CAS as they evolve from early childhood to adolescence.

www.pluralpublishing.com

THIRD EDITION

Here’s How to Treat Childhood Apraxia of Speech

The authors take a deep dive into application of evidence-based treatment strategies for children with CAS, and move beyond theoretical ideas to provide recommendations of specific activities to facilitate improved speech praxis in children across age groups, making this book extremely informative and practical. This latest edition maintains the original intention of the prior editions—to provide clinicians and students with a holistic look at the complex needs of children with CAS and to offer practical ideas for evaluation and treatment. The amount of new research over the past several years has been substantial. Fortunately for the readers, Here’s How to Treat Childhood Apraxia of Speech, Third Edition summarizes the most current research regarding the nature of CAS, best practices in evaluation, and effective treatment strategies to give clinicians greater confidence in working with children with this complex speech disorder.

Fish Skinder-Meredith

Here’s How to Treat Childhood Apraxia of Speech, Third Edition offers clinicians and students of speech-language pathology (SLP) a comprehensive look at the assessment, differential diagnosis, and treatment of childhood apraxia of speech (CAS). This book helps guide the SLP on which assessment tasks will provide the information needed to make a confident diagnosis of CAS at different stages of development, as well as best practices for treatment of CAS.

Here’s How to Treat Childhood Apraxia of Speech THIRD EDITION Margaret Fish Amy Skinder-Meredith

Here’s How to Treat Childhood Apraxia of Speech Third Edition

“Here’s How” Series Editor Thomas Murry, PhD Here’s How to Do Therapy:  Hands on Core Skills in Speech-Language Pathology, Third Edition Debra M. Dwight, EdD Here’s How to Do Accent Modification: A Manual for Speech-Language Pathologists Robert McKinney, MA, CCC-SLP Here’s How to Teach Voice and Communication Skills to Transgender Women Abbie Olszewski, PhD, CCC-SLP, Selah Sullivan MS, CCC-SLP, and Adriano Cabral, BA, MFA

Here’s How to Treat Dementia Jennifer L. Loehr, MA, CCC-SLP and Megan L. Malone, MA, CCC-SLP Here’s How to Provide Intervention for Children With Autism Spectrum Disorders:  A Balanced Approach Catherine B. Zenko, MS, CCC-SLP and Michelle Peters Hite, MS, CCC-SLP Here’s How to Do Early Intervention for Speech and Language:  Empowering Parents Karyn Lewis Searcy, MA, CCC-SLP Here’s How to Do Stuttering Therapy Gary J. Rentschler, PhD Here’s How Children Learn Speech and Language: A Text on Different Learning Strategies Margo Kinzer Courter, MA, CCC-SLP

Here’s How to Treat Childhood Apraxia of Speech Third Edition

Margaret Fish, MS, CCC-SLP Amy Skinder-Meredith, PhD, CCC-SLP

5521 Ruffin Road San Diego, CA 92123 e-mail: [email protected] Website: http://www.pluralpublishing.com Copyright © 2023 by Plural Publishing, Inc. Typeset in 10.75/14 Stone Informal by Flanagan’s Publishing Services, Inc. Printed in the United States of America by Integrated Books International All rights, including that of translation, reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher. For permission to use material from this text, contact us by Telephone: (866) 758-7251 Fax: (888) 758-7255 e-mail: [email protected] Every attempt has been made to contact the copyright holders for material originally printed in another source. If any have been inadvertently overlooked, the publisher will gladly make the necessary arrangements at the first opportunity. Library of Congress Cataloging-in-Publication Data: Names: Fish, Margaret A., 1959- author. | Skinder-Meredith, Amy, author. Title: Here’s how to treat childhood apraxia of speech / Margaret Fish, Amy Skinder-Meredith. Other titles: Here’s how series Description: Third edition. | San Diego, CA : Plural Publishing, Inc., 2022. | Series: Here’s how | Includes bibliographical references and index. Identifiers: LCCN 2022019111 (print) | LCCN 2022019112 (ebook) | ISBN 9781635502831 (paperback) | ISBN 1635502837 (paperback) | ISBN 9781635502848 (ebook) Subjects: MESH: Apraxias--therapy | Speech Disorders--therapy | Speech Therapy--methods | Child Classification: LCC RJ496.A63 (print) | LCC RJ496.A63 (ebook) | NLM WL 340.1 | DDC 618.92/855--dc23/eng/20220727 LC record available at https://lccn.loc.gov/2022019111 LC ebook record available at https://lccn.loc.gov/2022019112

Contents

Foreword by Edythe A. Strand, PhD, CCC-SLP

vii

Acknowledgments xi Chapter 1

Understanding Childhood Apraxia of Speech   1

Chapter 2

Assessment and Differential Diagnosis of Childhood Apraxia of Speech   33

Chapter 3

Fundamentals of Treatment for Childhood Apraxia of Speech   117

Chapter 4

Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech  173

Chapter 5

Establishing Vowel Accuracy and Natural Prosody   203

Chapter 6

Facilitating Speech and Language in Minimally Verbal Children   243

Chapter 7

Addressing Early Literacy Concerns in Children With Childhood Apraxia of Speech  273

Chapter 8

Supporting the Needs of Older Children With Ongoing Communicative Challenges  283

Chapter 9

Treating Children With Co-Occurring Disorders   317

Chapter 10 Considerations in Treatment of Childhood Apraxia of Speech Via Telepractice  335 Chapter 11 The Changing Needs of Children Over Time   343 Chapter 12 Developing Meaningful Goals and Collecting Data   359 Chapter 13 Partnering With Parents to Maximize Treatment Outcomes   375

Glossary 391 Index 397 This note icon will be found throughout the text to bring added attention to key points.

v

Foreword

T

he clinical practice and especially the science associated with childhood apraxia of speech (CAS) are relatively new compared to many other communicative disorders. In the last 20 years, there has been an explosion of work in this area, in terms of both basic science and clinical assessment tools and treatment strategies. This third edition of Here’s How to Treat Childhood Apraxia of Speech adds to that literature in a very practical way. It is not always easy to bridge the gap between research and the application of that research to clinical practice. The authors are excellent clinicians who have brought that broad experience to this book. They reviewed a great deal of the science and evidence base in a way that practicing clinicians will appreciate and be able to use. Further, the authors recognize that every child brings individual challenges with respect to severity, personality, previous experience with therapy, comorbidities, and parent involvement, and they provide ways to approach these challenges. The 13 chapters of this edition cover a wide range of topics. Chapter 1 discusses the nature of CAS, the neurological implications, genetic variants associated with the disorder, the core characteristics, and many associated disorders that may occur with CAS. Chapter 2 focuses on assessment strategies leading to differential diagnosis of CAS. Here the authors provide a framework for assessment in general and strategies for evaluation that covers cognition and language as well as speech. They provide some direction for assessing children for whom English is not their first language and give specific strategies for different ages, encouraging clinicians to use clinical thinking when devising assessment protocols for individual children. There are many tables and worksheets that clinicians may find helpful for assessing children with CAS, as well as many children with other types of speech sound disorders. Chapter 3 focuses on the fundamentals of treatment, with special attention to the principles of motor learning, the application of which is essential in the treatment of CAS. In addition to providing a broad description of several important principles to incorporate into treatment, the authors provide many practical tasks to allow for the repetitive practice often required in treating CAS. Further, they describe different activities that may apply to a variety of children and contexts. The authors discuss both external and internal evidence to inform treatment decisions in Chapter 4. They describe the different published treatment methods and the evidence that has been shown for their efficacy. Chapter 5 focuses on treatment strategies for vowel accuracy and natural prosody, both which are common areas of difficulty for children with CAS. This book, however, goes beyond treatment specific to CAS. For example, Chapter 6 focuses on activities for minimally verbal children including children at risk for CAS or any child who may need very early speech-language intervention. Parents and caregivers will appreciate tables related to developmental milestones as well as activities that support early language and speech development.

vii

viii   Here’s How to Treat Childhood Apraxia of Speech

While Chapter 7 addresses early literacy in CAS, the treatment strategies suggested would likely be appropriate for many children with speech sound disorders who are having trouble learning to read. The authors provide a thorough discussion of the types of phonological awareness and early literacy challenges as well as suggestions for working with these challenges in the context of speech sensorimotor planning treatment. Likewise, clinicians will appreciate Chapter 8 in which strategies for supporting the needs of older children are discussed. These strategies addressing residual articulation errors, persistent phonological patterns, cluster reduction, and reduced comprehensibility will be extremely helpful for older children with CAS as well as children with other speech sound disorders. While the authors discussed many ways to facilitate expressive language development in younger children in Chapter 6, this chapter provides information in treating ongoing language issues. Strategies for improving vocabulary, grammar, conversational skills, and use of language in social interactions will be widely appreciated by clinicians. Two important additional chapters appear in this edition: treating children with concomitant disorders and considerations of treatment via telepractice. Many children with CAS present with a large variety of co-occurring disorders. Expressive language impairment and phonological disorders are very common, and practical suggestions for addressing these linguistic deficits are presented throughout the book. Described in Chapter 9 are treatment strategies for those children who also exhibit dysarthria, attention deficit hyperactivity disorder, autism, and developmental coordination disorder. Also discussed is how to improve social interaction skills for children with social-emotional difficulties and/or anxiety around communication. Parents as well as clinicians will appreciate the practical suggestions in this chapter. Given the COVID-19 pandemic, more treatment has been and will likely continue to be offered via telepractice. In Chapter 10, the authors give recommendations for telepractice for speech and language in general as well as specific suggestions for children with CAS. This is a timely and important issue. Chapters 11 and 12 focus on how to address changing needs of the child over time and how to address that in therapy as well as writing meaningful goals and collecting data. While this certainly pertains to treating CAS, the issues discussed will be helpful to clinicians working with a variety of children with speech and language disorders. Importantly, the authors also provide helpful information regarding home practice and working with parents. The breadth of this book is large and will therefore be of interest to a variety of audiences. Students and clinicians will find many of the practical strategies and worksheets provided to be extremely helpful in their clinical practice. Parents will find it useful for understanding the nature of their child’s speech problem and feel empowered by the authors’ emphasis on including parents in the management of their child’s speech problems. Margaret Fish and Amy Skinder-Meredith are experienced, excellent clinicians. They have spent many years specializing in the assessment and treatment of children with severe speech sound disorders. They have a great deal of experience in treating CAS, providing courses and workshops on the management of CAS for both students and practicing clinicians, and volunteering many hours to support families of children with CAS. This rich experience is evident throughout this book. Students and clinicians will appreciate the many intervention ideas based on best practice. The authors’ desire to bring the literature to clinical application is evident in this book. I know them to have a passion for helping children with speech and language deficits, especially CAS, and it shows. They are enthusiastic in their endeavors to educate students and clinicians in pediatric motor speech disorders. This book continues that

2.  Assessment and Differential Diagnosis of Childhood Apraxia   ix

work. The scope of the strategies presented for assessment and treatment is wide ranging, clearly written, and clinically applicable. Management of CAS is complicated, challenging, and rewarding. This book provides guidance and support that will be appreciated by many. Edythe A. Strand, PhD, CCC-SLP Emeritus Professor, Mayo College of Medicine Emeritus Consultant, Department of Neurology,   Mayo Clinic Rochester, Minnesota Affiliate Professor, University of Washington Department of Speech and Hearing Sciences Seattle, Washington

Acknowledgments

W

e have so many colleagues to thank who supported us in myriad ways throughout the writing of this book. We would first like to thank Dr. Edythe Strand (Edy) for paving the way for us to have a better understanding of CAS back when we started this journey over 20 years ago. Edy’s vast knowledge of pediatric motor speech disorders is matched by her warmth and compassion, which she generously shares with her clients, families, students, and colleagues. Her willingness to write the Foreword was truly an honor. We would also like to thank Nancy Potter, who read through and edited chapters, in addition to being a sounding board about what should be included in the book over many miles of cross-country skiing, hiking, biking, and office conversations. Many of our colleagues were incredibly generous with their time in responding to our questions about their research, by engaging in professional dialogue, sharing information and resources, reading through early drafts, and provided much needed encouragement and ongoing support. We are grateful for the work they do for children with CAS and their families. Thanks to Angela Morgan, Aravind Namasivayam, Beate Peter, Deb Hayden, Edwin Mass, Heather Rusiewicz, Jan Norris, Jenya Iuzzini-Seigel, Jonathan Preston, Laura Moorer, Megan Hodge, Megan Overby, Christina Gildersleeve-Neumann, Nancy Kaufman, Nancy Tarshis, Pamela Williams, Patricia McCabe, Ruth Stoeckel, Sharynne McLeod, Shelly Velleman, and Susan Caspari, for sharing their expertise throughout our writing process. We would also like to thank the founder of Childhood Apraxia of Speech of North America (CASANA), Sharon Gretz. If it wasn’t for Sharon and the original CASANA team with Kathy Hennessey and Mary Sturm (three fearless mothers of children with CAS), many of us would not have met each other and forged the collaborations across the country and world we have today to support children and families with CAS. We are grateful for the Executive Director of Apraxia Kids (formerly known as CASANA), Angela Grimm, for continuing the mission to improve the lives of children with CAS and help each child with CAS find their voice. This book wouldn’t have been possible without the support of our talented and dedicated team at Plural Publishing. Thanks to Emily Pooley, Valerie Johns, Lori Asbury, Jessica Bristow, and Kristin Banach who were responsive to our many questions over the past several months. They have been instrumental in keeping the production on track and refining the manuscript. Last, but not least, we are eternally grateful for the children and the families we have worked with, who are our greatest teachers. We are appreciative of their resilience, patience, hard work, tenacity, stories, and humor.

xi

For John, Jackie, and Michael, who fill my world with joy. MAF

For Todd, Alisher, and Jasmine, who have made life an amazing adventure. ASM

CHAPTER

1

Understanding Childhood Apraxia of Speech

I

n 2007, the American Speech-Language-Hearing Association’s (ASHA) technical report on childhood apraxia of speech (CAS) provided a definition of this complex neurological pediatric motor speech disorder that impacts both articulatory accuracy and prosody. The report provided three core characteristics observed in CAS that help the clinician differentiate it from other speech sound disorders and a list of frequently co-occurring challenges. The quest to fully understand CAS, however, keeps researchers and speech-language pathologists (SLPs) in a constant state of investigation and learning. The purpose of this chapter is to provide an overview of the journey of our understanding of CAS — from the initial discovery in the 1950s to what we currently know based on behavioral, acoustic, kinematic, genetic, and brain imaging research.

What Is CAS? CAS falls under the umbrella of speech sound disorders (SSDs) as shown in Figure 1–1. SSDs can be due to motor-based articulation challenges, structural differences, sensory deficits, or linguistically based phonological issues. A child with an SSD could have a combination of factors making speech production difficult. For example, a child could have speech impacted by hearing loss and cleft lip and palate, in addition to CAS.

History of CAS The history of apraxia of speech in children is an interesting one. It was first noted by Morley, Court, and Miller in 1954 in the United Kingdom. In 1950, these authors proposed a taxonomy to classify childhood speech disorders. They used the following five broad categories: deafness, defective articulation or dysarthria, retarded development of language or

1

2   Here’s How to Treat Childhood Apraxia of Speech

Figure 1–1.  Speech Sound Disorders Classification System. (Modified from Speech sound disorders: Articulation and phonology [Practice portal] by American Speech-Language-Hearing Association, n.d., https://www.asha.org/ Practice-Portal/Clinical-Topics/Articulation-and-Phonology/. Reproduced with permission from ASHA.)

dysphasia, dyslalia, and stammering. When they further examined the children with dysarthria in their 1954 paper, they noted that there was a subgroup of children whose lips, tongue, and palate appeared normal on voluntary movements but clumsy and awkward when they attempted the more complex and rapid movements required of speech. They labeled the disorder, “dyspraxic dysarthria” or “articulatory dyspraxia.” In the United States, researchers Rosenbek and Wertz (1972) were bringing attention to a set of speech characteristics observed in children with SSDs that, in many ways, resembled the apraxia of speech affecting adults following stroke or brain injury. These children appeared to have the strength and structural integrity of the speech mechanism to be capable of speaking clearly; however, they demonstrated significant difficulty in speech production, including difficulty with phoneme sequencing, inconsistent errors, groping for sounds, difficulty imitating oral movements, difficulty imitating sounds and words, and atypical stress and intonation patterns. These children did not respond as expected to traditional types of speech therapy, often making very slow progress. Given the similarities of the nature of the speech difficulties of these children to adults with acquired apraxia, researchers began to label these children as apraxic or dyspraxic. Over the years, terms such as developmental apraxia of speech, childhood verbal apraxia, developmental verbal apraxia, developmental verbal dyspraxia, and CAS have been used to describe these types of speech characteristics in children. The term childhood apraxia of speech (CAS) was recommended by ASHA in 2007 as the classification term for children who demonstrate certain types of speech characteristics (e.g., inconsistent articulation errors, disordered prosody, and poor coarticulation). These characteristics are detailed in the following section. CAS is estimated to occur in approximately one to two children per thousand (Shriberg et al., 1997a), with a higher prevalence occurring in children with certain syndromes or types of genetic deviations.

1.  Understanding Childhood Apraxia of Speech   3

Defining CAS To provide greater clarity for SLPs working with children with CAS, ASHA formed a committee (Ad Hoc Committee on Apraxia of Speech in Children) to review the available scientific research related to CAS. The committee also described current trends in professional management of CAS and made recommendations related to assessment, treatment, and future research. In its report (ASHA, 2007a), the committee proposed the following definition of CAS: Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody. (ASHA Position Statement, 2007, para. 3)

There is a lot of information packed in this definition, so let us break it down: CAS is a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.

What Do We Know About the Neurological Component? Although some children with CAS may have a history of clear neurological involvement, such as an intrauterine stroke, infections that attack the brain, epilepsy, or trauma, the majority do not. However, this does not rule out a neurological component. Brain imaging and genetic studies over the past two decades have revealed more insight into the neurological differences of children with CAS. This has not been an easy or straightforward discovery. Unlike adults with acquired apraxia of speech, children with CAS do not typically present with a focal brain lesion in the left hemisphere. The heterogeneity of the disorder also caused challenges when using neuroimaging studies that looked only at the brain morphology. Studies prior to the completion of the human genome project (1990–2003) and availability of more sophisticated neuroimaging tools, like functional magnetic resonance imaging (fMRIs) and diffusion tensor imaging, limited researchers in their ability to better understand the genetics and neural correlates that correspond with motor planning and sequencing for speech and the other characteristics frequently associated with CAS, such as language and literacy impairments. Advancements in neuroimaging and genetic testing methods have put us on an exciting trajectory of learning more about these children we care so deeply about. No story illustrates the evolution of genetic and neurological discoveries better than the account of the KE family. In the late 1980s, the KE family caught the attention of a special educator in Brentford, England. The teacher, Ms. Auger, noticed she had several members of the same family that presented with motor speech and language disorders. Assuming these traits were heritable, she contacted Jane Hurst, a geneticist and researcher (Fowler, 2017). When examining three generations of the KE family, they discovered that the grandmother, four of her five children, and 11 of her 23 grandchildren had CAS in addition to other challenges,

4   Here’s How to Treat Childhood Apraxia of Speech

showing this to be an autosomal dominant monogenic trait (Hurst et al., 1990). With the advancements made in genetics (e.g., semiautomatic genotyping), Fisher and colleagues (1998) were able to localize the gene responsible, FOXP2 (SPCH1) on the chromosomal band 7q31. To investigate the neural correlates, the team did brain imaging on affected and unaffected family members (Vargha-Khadem et al., 1998). In the areas of speech, language, and orofacial praxis development, all the affected family members were significantly more impaired than the unaffected members. By analyzing the results produced by positron-emission tomography (PET) activation scans during a word repetition task and magnetic resonance imaging (MRI) scans, the authors found that affected family members had functional and structural abnormalities. PET scan results revealed reduced activity in the left supplementary motor area (SMA), the left cingulate cortex, and the left preSMA/cingulate cortex. Overactive regions included the head and tail of the left caudate nucleus, the left premotor cortex with a ventral extension into Broca area, and the left ventral prefrontal cortex. Consistent with these findings, the MRI scans of affected members revealed significantly more gray matter in the lentiform nucleus (putamen and globus pallidus) and angular gyrus bilaterally and less gray matter in the preSMA/cingulate cortex Broca area, and the caudate nucleus bilaterally than the unaffected members. Authors speculated that the bilateral reduction in the volume of the caudate nucleus may explain the orofacial dyspraxia and verbal apraxia. A follow-up study using fMRIs during a nonsense word repetition task confirmed and added to these findings. Results showed that the affected members had significantly reduced activity in the premotor, supplementary, and primary motor cortices, as well as in the cerebellum and basal ganglia (Liégeois et al., 2011). See Figure 1–2 for the neural correlates. These findings led to more research on the FOXP2 gene, yet it was found that this gene only accounted for a small number of cases of CAS. As brain imaging and genetic analysis have become more sophisticated, more neurological and genetic links to CAS are being discovered. Chilosi and colleagues (2015) examined 32 Italian children with idiopathic CAS for genetic and brain morphology differences. Although 70% of the children with CAS had parents or relatives with language disorders, dyslexia, or both, only six of the children had a known genetic alteration, where three of the genetic abnormalities were inherited from a parent and one was a de novo genetic alteration. De novo refers to a new mutation, one not inherited from either parent. Interestingly, the parents who passed on the gene did not present with a history of CAS and appeared phenotypically normal with none of the gene alterations involved the FOXP2 gene. Findings from conventional MRI images of the 32 participants did not show significant visible neuroanatomical abnormalities and suggested CAS may be due to microstructural alterations in the brain. A follow-up study using diffusion tensor imaging (DTI) (Fiori et al., 2016) found differences in the structural connectivity of speech and language networks. Using this approach, researchers were able to determine three intrahemispheric and interhemispheric subnetworks that had reduced connectivity when compared to controls. When one thinks about reduced connectivity of a neural pathway, it helps to conceptualize these connections as ranging from slow and inefficient, like a hard-to-find path that has you bushwhacking through the forest, to a superhighway that allows you to move quickly. When a child has CAS, they may lack some of the superhighways that provide rapid connections for effortless acquisition of speech, language, and literacy skills. See Table 1–1 for a summary of the results of Fiori and colleagues (2016). From a theoretical basis, connectivity issues discovered by Fiori and colleagues (2016) correlate with deficits in the areas presented in Table 1–2.

1.  Understanding Childhood Apraxia of Speech   5

Figure 1–2.  A. Brodmann areas shown on the literal surface of the left hemisphere. B. Brodmann areas shown on the medial surface of the right hemisphere. (From Clinical neuroscience for communication disorders: Neuroanatomy and neurophysiology, by M. Lehman Blake and J. K. Hoepner, 2023, p. 8, Figure 1–8. ©Plural Publishing.)

6   Here’s How to Treat Childhood Apraxia of Speech

Table 1–1.  Impacted Subnetworks and Structures and Corresponding Behavioral Consequences Network

Structures Involved

Significant Correlations

Subnetwork 1

Left inferior and superior frontal gyrus, left superior and middle temporal gyrus, and left posterior–central gyrus.

Low performance on oromotor skills Low DDK rate Poor expressive grammar Poor lexical production

Subnetwork 2

Right supplementary motor area, left middle and inferior frontal gyrus, left precuneus and cuneus, right superior occipital gyrus, and right cerebellum

Low DDK rate

Subnetwork 3

Right angular gyrus, right superior temporal gyrus and right inferior occipital gyrus

No correlation found

Table 1–2.  Neural Structures and Their Behavioral Correlates Impacted in Research Participants With CAS

Neural Structures Involved

Proposed Functions of the Neural Structure

1

Middle and superior temporal gyri

Phonemic discrimination

1

Inferior frontal gyrus

Phonological and syntactic processing Feedback-based articulatory control

1

Temporal-frontal connectivity disruption

Mismatch between auditory feedback and oromotor control

2

Precuneus

Conceptual planning during lexical search Action initiation

2

Right supplementary motor area (SMA)

Speech planning and motor and cognitive triggering

2

Cerebellum Cerebellum + SMA

Alteration in feed-forward mechanisms of speech control Altered motor planning

Angular gyrus

Semantic representation

Subnetwork

3

Note.  Data from “Neuroanatomical Correlates of Childhood Apraxia of Speech: A Connectomic Approach,” by S. Fiori, A. Guzzetta, J. Mitra, K. Pannek, R. Pasquariello, P. Cipriani, M. Tosetti, G. Cioni, S. Rose, and A. Chilosi, 2016, NeuroImage: Clinical, 12, pp. 894–901. https://doi.org/10.1016/j.nicl.2016.11.003

Treatment studies have provided additional information on neurological differences of the brain in children with CAS. In 2014, Kadis and colleagues found differences in cortical thickness in the left posterior supramarginal gyrus when using vertex-based thickness analysis with high-resolution MRIs. Prior to treatment, children with idiopathic CAS had thicker left posterior supramarginal gyri than controls. Eight weeks post PROMPT (PROMPTS for Restructuring Oral

1.  Understanding Childhood Apraxia of Speech   7

Muscular Phonetic Targets) treatment, eight of the nine children with CAS showed thinning of this area, suggesting increased neural plasticity of the brain with the pruning of unnecessary neurons for more efficient motor speech planning. Fiori et al. (2021) examined the behavioral and neurological impact of PROMPT compared to a language, nonspeech oral motor training (LNSOM) approach. Results indicated both groups had a favorable change in the corticobulbar pathways for speech motor control, with greater changes in the PROMPT group. More specifically, the use of fractional anisotropy indicated an increase in the left dorsal and ventral corticobulbar tracts. When interpreting results of studies that use fractional anisotropy, it helps to understand the basic premise. “Reduction of fractional anisotropy and related increase of mean diffusivity are reported to be associated with impaired connectivity, whereas processes connected with learning can determine neuroplastic effects and have been associated with fractional anisotropy increase and mean diffusivity decrease” (Fiori et al., 2021, p. 965). Although a correlational analysis between severity of motor speech control and measures of diffusivity were unable to be performed, positive changes were seen in both areas. In addition to studies giving us insight into the compromised neural networks for children with CAS, they also show how appropriate therapy can strengthen these pathways. It is exciting to know that, with appropriate therapy implementation, SLPs have the tools to change the brain. To summarize, the neuroanatomical and physiological differences found thus far in children with CAS include the following areas: left posterior central gyrus (1, 2, 3); primary motor cortex (4); left premotor cortex (6); left precuneus (7); left cuneus (17); right superior occipital gyrus (19); left middle temporal gyrus (21); left caudate nucleus (23); left cingulate cortex (32); left and right superior temporal gyrus (41); Broca area (44, 45); and left ventral prefrontal cortex (46); in addition to the basal ganglia and cerebellum. See Figure 1–2 for a reference to the Brodmann areas and Figure 1–3 for the basal ganglia and cerebellum.

Figure 1–3. Structures of the basal ganglia, thalamus, and cerebellum from the lateral view of the left hemisphere. (From Clinical neuroscience for communication disorders: Neuroanatomy and neurophysiology, by M. Lehman Blake and J. K. Hoepner, 2023, p. 27, Figure 1–30. ©Plural Publishing.)

8   Here’s How to Treat Childhood Apraxia of Speech

What Is Meant by Precision and Consistency of Movements? As an SLP, you understand this. As a layperson, unfamiliar with how difficult acquisition of speech is for some children, the planning and executing of articulatory movement is a skill that is often taken for granted. Speech is a complex motor task requiring numerous muscles of the four speech subsystems (respiration, resonance, phonation, articulation) to work together efficiently in a coordinated manner. The coordination of these movements needs to be precise and consistent, yet flexible. To illustrate the motoric complexity of speech, think of all the steps that go into saying the word, “can” as in, “Can I go too?” It is a simple CVC, but let’s break it down. 1. Cognitively, we need to have communicative intent to make this request. 2. Linguistically, we need to have the word in our lexicon, retrieve the word, and have a representation of it. For the full phrase, we need to have the sentence structure and know where to put stress. 3. Immediately prior to producing the sequence of phonemes (motor execution), we need to plan and program the movement parameters. For the word “can,” we need to prepare to do the following: a. Take a quick inhalation to be ready to speak on exhalation. b. Raise the velum and constrict the pharyngeal walls to close off the velopharyngeal port so no air escapes out the nose while building pressure for /k/. c. Raise the back of the tongue to contact the soft palate while thinking ahead for where the /ᴂ/ will be. (Note that placement for /k/ before /ᴂ/ is different than for /u/.) d. Abduct the vocal folds for the /k/ so it is not voiced. e. Release pressure in ~50 ms to produce the /k/ sound. f. Get ready for /ᴂ/ by opening the jaw slightly and dropping the tongue to the mid- front position and getting ready to phonate. g. Adduct and vibrate vocal folds while the tongue is in the front-low position for /ᴂ/ with onset of voice occurring approximately 50 ms following initial onset of /k/. h. Start to open the velopharyngeal (VP) port to get ready for /n/ while still phonating /ᴂ/. i. Continue phonation while fully opening the VP port and move tongue tip to the alveolar ridge to produce /n/. j. Drop the tongue tip and lower the jaw as you get ready for “I.” Wow, that was a lot of movement to plan for, and there are still several more words in the sentence to get through. When we appreciate the precision and speed of movement necessary for speech, it is amazing any of us can talk. That was just the precision part. Now think about the consistency. Speech is a motor skill, and some would add that it is a sensory-motor (or sensorimotor) skill, as you use your sensory feedback on how speech sounds and feels to know where to place the articulators. Early skill acquisition heavily relies primarily on a feedback strategy in which children observe the outcome of their action and make adjustments during

1.  Understanding Childhood Apraxia of Speech   9

future trials. With maturity, experience, and practice, children transition from reliance on feedback and begin to incorporate more feed-forward strategies, such as anticipating the required force, distance, and direction of movement prior to the execution of an action (Potter et al., 2009). This is why when learning a new motor skill, we tend to be inconsistent. It takes a lot of trial and error to get it right and hence a lot of practice.

What Is This About the Absence of Neuromuscular Deficits? When this statement was initially written, many SLPs thought this meant that dysarthria had to be ruled out to diagnose a child with CAS. We now recognize that a child can have both CAS and dysarthria, among other challenges that impact communication. Of the 32 children Murray and colleagues (2015) studied with idiopathic CAS, four also had dysarthria. Hence, this is not an either/or situation. The SLP needs to tease out which aspects of the child’s speech sound disorder are due to difficulty with motor planning and programming versus other underlying factors. A child with dysarthria will have imprecise movement due to difficulties with the execution portion of speech production, but the errors tend to be consistent, while the child with CAS will have inconsistent errors. This is addressed more in Chapter 2. CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.

What Is Known About Complex Neurobehavioral Disorders Associated With CAS? Recent studies by Shriberg, Strand, Jakielski, and Mabie (2019) examined the prevalence of motor speech disorders in children with complex neurodevelopmental disorders (CNDs). In a companion study, Shriberg, Kwiatkowski, and Mabie (2019) calculated the prevalence of motor speech disorders in children with idiopathic speech delay (SD). Speech samples of 346 children with one of eight types of CNDs, with an average age of 13.3 years, were studied to determine prevalence of speech sound disorder classifications for this population. In the companion study, there were 415 participants with idiopathic speech delay, and most participants were preschool age or in early primary grades (M = 5.5 years of age; SD = 1.4). See Figures 1–4 and 1–5 for the percentage of children in each group diagnosed as not having a motor speech disorder (no MSD), speech motor delay (SMD), childhood dysarthria (CD), CAS, and childhood apraxia of speech with childhood dysarthria (CAS + CD). When interpreting these graphs, it is important to note that SSDs can evolve over time and that the speech samples used for this research captured only a moment in time. The children with idiopathic CAS were an average age of 5.5 years and had no co-occurring CD, whereas the children with complex neurodevelopmental disorder (CND) were an average age of 13.3 years, and 5% had both CAS and CD. It has been our experience, as SLPs who work primarily with children with motor speech disorders from early childhood through adolescence, that for some children a dysarthric component becomes more apparent as the motor sequencing improves. In other words, the child’s sequence of articulatory movement becomes more accurate, but some of the phonemes are still weak and imprecise.

Figure 1–4. Estimates of prevalence of motor speech disorders in children with complex neurodevelopmental disorders. Adapted from Shriberg, L. D., Strand, E., Jakielski, K. J., & Mabie, H. L. (2019). Estimates of the prevalence of speech and motor speech disorders in persons with complex neurodevelopmental disorders. Clinical Linguistics & Phonetics, 33(8), 707–736. https://doi.org/1 0.1080/02699206.2019.1595732

Figure 1–5. Estimates of prevalence of motor speech disorders in children with idiopathic speech delay. Adapted from Shriberg, L. D., Kwiatkowski, J., & Mabie, H. L. (2019). Estimates of the prevalence of motor speech disorders in children with idiopathic speech delay. Clinical Linguistics & Phonetics, 33(8), 679–706. https:// doi.org/10.1080/02699206.2019 .1595731

10

1.  Understanding Childhood Apraxia of Speech   11

The relatively new classification of speech motor delay (SMD) may also be why our clinical perceptions are not consistent with the research. Speech motor delay used to be referred to as motor speech delay not otherwise specified (MSD-NOS). SMD is characterized by imprecise and unstable speech, prosody, and voice that does not meet criteria for either CD or CAS (Shriberg, Kwiatkowski, & Mabie, 2019; Shriberg, Strand, et al., 2019). It is considered a disorder of execution instead of motor planning and programming, as in CAS. It is “a delay in the development of neuromotor precision-stability of speech motor control” (Namasivayam et al., 2020, p. 16). Assessment methods used in the research by Shriberg, Kwiatkowski, and Mabie, (2019), Shriberg, Strand, et al., (2019), and Namasivayam et al. (2020) allow for more precise classification, which can provide insight for the SLP. However, the time it takes to do the detailed speech and kinematic analysis for the classification of SMD versus CAS versus CD versus CAS + CD is not typically feasible for the practicing SLP currently. Hence, Chapter 2 focuses on what is practical and helps guide the clinician to make an appropriate treatment plan.

What Have Studies Revealed About Genetic Variants Implicated in CAS? Most cases of CAS are currently considered idiopathic, meaning we do not know what the cause is. However, with the rapid gains being made in genetics research, we are learning more about the gene mutations that play a role in neurodevelopment. SLPs involved in the research of genetics of CAS and other speech and language disorders (e.g., Graham & Fisher, 2015; Laffin et al., 2012; Lewis et al., 2011; Morgan, 2020; Peter et al., 2012; Vargha-Khadem et al., 2005; Velleman & Mervis, 2011) have helped our field tremendously in better understanding the link between gene variants and the behavioral characteristics related to speech, language, literacy, and cognition. It is currently estimated that 32% to 44% of children with CAS have an associated genetic variation (Eising et al., 2019; Hildebrand et al., 2020). Some of the variants are inherited, passed from the parent to the child, and many are new variants (de novo) (Hildebrand et al., 2020). The availability of new cost-efficient genetic technologies and the hard work of many researchers have brought us to a place of great discovery. If a parent had asked their SLP if genetic testing was worth the expense and effort prior to 2015, the answer probably would have been no. However, methods like whole genome sequencing have become more affordable at approximately one thousand dollars per individual in 2022. Children who present with neurodevelopmental conditions (e.g., attention deficit hyperactivity disorder [ADHD], epilepsy, autism spectrum disorder [ASD], motor impairments) in addition to CAS should be referred for genetic testing, as it can assist with a clearer diagnosis and prognosis (Dodd, 2021; Morgan et al., 2021; Peter et al., 2012). In addition, the diagnosis will guide intervention, may qualify a child for earlier intervention or increased insurance coverage, and potentially offer the family more support, as some genetic diagnoses have a related support group (e.g., SETBP1 haploinsufficiency disorder, 22q11.2 deletion, and galactosemia). Genetic variations related to CAS can be divided into three categories: (a) single gene variants, where there is an alteration in the gene; (b) copy number variants (CNVs), where there can be small or large deletions, duplications, or rearrangements of sections of a chromosome; and (c) other genetic syndromes, where CAS sometimes occurs. Examples of single gene variants and CNVs are presented in Table 1–3. Some of the genetic syndromes and disorders that may or may not have a CAS component include Noonan syndrome, Down syndrome, fragile X syndrome, Klinefelter syndrome, and classic galactosemia (Potter et al., 2013). These single gene variants, CNVs, and other genetic syndromes can be associated with a wide range of behavioral and physical characteristics. As with any genetic condition or

12   Here’s How to Treat Childhood Apraxia of Speech

Table 1–3.  Examples of Single Gene Variants and Copy Number Variations Associated With CAS Single Gene Variants

a

Copy Number Variations

CDK13a

GNAO1a

MKL2

UPF2a

5q14.3q21.1a

CHD3

GNB1a

POGZ a

WDR5

7q11.23 duplication syndrome

DDX3Xa

GRIN2A

SETBP1a

ZFHX4

16p11.2 deletion

EBF3a

KAT6A

SETD1A

ZNF142

17q21.31 microdeletion (Koolen de Vries syndrome)

FOXP2

MEIS2

TNRC6B

22q11.2 deletion syndrome

These are de novo variations (i.e., not passed down from either parent).

Notes. 2018 Information from “A Set of Regulatory Genes Co-expressed in Embryonic Human Brain Is Implicated in Disrupted Speech Development,” by E. Eising, A. Carrion-Castillo, A. Vino, E. Strand, K. Jakielski, T. Scerri, . . . S. Fisher, 2019, Molecular Psychiatry, 24(7), 1065–1078, https://doi.org/10.1038/s41380-018-0020-x; “A Highly Penetrant Form of Childhood Apraxia of Speech Due to Deletion of 16p11.2,” E. Fedorenko, A. Morgan, E. Murray, A. Cardinaux, C. Mei, H. Tager-Flusberg, . . . N. Kanwisher, 2016, European Journal of Human Genetics, 24, 302–306, https://doi.org/10.1038/ejhg.2015.149; “Severe Childhood Speech Disorder: Gene Discovery Highlights Transcriptional Dysregulation,” M. S. Hildebrand, V. E. Jackson, T. S. Scerri, O. Van Reyk, M. Coleman, R. Braden, . . . A. Morgan, 2020, Neurology, 94(20), e2148–e2167, https://doi.org/10.1212/wnl.0000000000009441; “Novel Candidate Genes and Regions for Childhood Apraxia of Speech Identified by Array Comparative Genomic Hybridization,” by J. J. Laffin, G. Raca, C. A. Jackson, E. A. Strand, K. J. Jakielski, and L. D. Shriberg, 2012, Genetics in Medicine, 14 (11), 928–936, https:// doi.org/10.1038/gim.2012.72; “Deep Phenotyping of Speech and Language Skills in Individuals With 16p11.2 Deletion,” by C. Mei, E. Fedorenko, D. Amir, A. Boys, C. Hoeflin, P. Carew, T. Burgess, S. Fisher, and A. Morgan, 2018, European Journal of Human Genetics, 26, 676–686, https://doi.org/10.1038/s41431-018-0102-x

syndrome, no two children with the same diagnosis will present exactly alike. For example, where one child with 22q11.2 deletion may have velopharyngeal insufficiency, CAS, cardiac issues, and a language disorder, another might not have the CAS component but have ADHD and an intellectual disability. Regardless, if there is a known genetic diagnosis, it alerts the child’s parents and primary health care provider to be on watch for the symptoms the child is at high risk for, which can lead to better precision medicine and access to the appropriate health care providers (Morgan & Webster, 2018) (information about current clinical trials can be found at https://www.geneticsofspeech.org.au/research/ or https://clinicaltrials.gov/). The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.

What Are the Underlying Deficits That Result in the Core Impairment of Planning and Programming of Movement Sequences? Children diagnosed with CAS have various levels of challenge with planning and programming for speech, described eloquently by van der Merwe (2019). In the motor planning phase

1.  Understanding Childhood Apraxia of Speech   13

of speech, specifications are made related to placement and manner for articulatory movements, as well as the timing of specific movements for each sound. For example, to produce the word bee, the lips need to close but also to spread slightly in anticipation of the vowel “ee” to follow. For boo, the lips close but also round as an anticipatory response to the upcoming vowel “oo.” At the same time, the brain is also specifying the raising of the velum and vibration of the vocal folds at just the right time, for if the vocal fold vibration begins too late, the result would be “pea” and “poo,” rather than “bee” and “boo.” In the motor programming phase, the specifications of muscle movements related to muscle tone, velocity of movement, amount of force applied to the articulators, range of motion, and so on, are made. Both planning and programming these specifications of articulatory control occur prior to actual execution of the movement. When we consider the speed with which the brain needs to organize all this information, it becomes clearer how a breakdown in the planning and programming can have such a significant impact on speech in children with CAS. Although it is well accepted that the core impairment of CAS is because of faulty sensory and motor planning and programming (ASHA Technical Report, 2007b; Overby et al., 2019; Rosenbek & Wertz, 1972, several other theories have been proposed as well. When reading through the literature, it can sometimes feel like a “Which came first, the chicken or the egg?” question. For example, do infants later diagnosed with CAS have decreased speech-like vocalizations because they are unable to motor plan or program the movement, or did the ability to plan and program movement fail to develop normally because there was a lack of sensorimotor feedback? During this time, an infant’s brain is undergoing a mapping process, coupling articulator movements with sound production and sensory feedback. This phase is followed by a phonological stage where imitation and practice begin to solidify the mapping of articulatory movement to the specific goal (Overby et al., 2020). To account for the findings of disordered prosody, Shriberg and colleagues (1997b) suggested that for at least a subtype of CAS, there is a “stress deficit at the level of representational planning processes rather than the motor-speech programming processes” (Shriberg et al., 1997b, p. 324). Stress assignment is thought to occur at the linguistic level, which would occur prior to motor speech programming. It is represented in the instructions sent for prearticulatory processing by the programmer. Although disordered prosody was listed as a characteristic of CAS, Shriberg and colleagues brought observations of disordered prosody more to the forefront for differential diagnosis. Alternatively, Velleman and Strand (1994) posited that “children with CAS could be seen as impaired in their ability to generate and utilize frames, which would otherwise provide the mechanisms for analyzing, organizing, and utilizing information from their motor, sensory and linguistic systems for the production of spoken language” (pp. 119–120). Through this lens, we see the importance of paying attention to syllable shapes and syntax, areas in which the child with CAS is challenged. The focus of therapy is often on systematically increasing the complexity of the syllable shapes, while being mindful of the phonemes within those syllable shapes. Theoretically, this will allow the work on one set of phrases to generalize to a different set of phrases of similar syllable shape, length, and complexity. Through the investigation of auditory perception, discrimination, syllable identification, and rhyming tasks, other linguistic theories emerged. Marquardt and colleagues (2002)

14   Here’s How to Treat Childhood Apraxia of Speech

found that children with CAS had difficulty perceiving syllableness and comparing syllable representations. Built on previous findings of children with CAS not being able to recognize or produce rhymes (Marion et al., 1993), they concluded that speech motor programming deficits alone could not explain their findings. Rhyming tasks necessitate internal representation of the phoneme. Hence, difficulty with identifying and producing rhymes indicates poor phonemic representations that allow rhyming to occur. Children with CAS also had difficulty performing syllable tasks that included awareness of syllables, identifying the location of phonetic differences, and constructing syllable shapes (Marquardt et al., 2002). Based on these findings, they hypothesized that the disorder is due to an impoverished phonological representation system, where the linguistic integrity of the underlying phonological structures is compromised. Because the neural substrates representing the phonological framework of the child’s speech motor programming performance are disordered, the speech motor output is severely handicapped as the phonological targets driving articulation could be totally missing or marginal. This could account for the difficulty children with CAS have producing complex syllable shapes and multisyllabic words, in addition to spelling and decoding. In another body of research from the Netherlands, Groenen and colleagues (1996) found that children with CAS had poor discrimination of consonants with subtle acoustic differences and vowels, which leads to difficulty with speech. There have also been discussions about CAS being linked to implicit motor learning difficulties, which interferes with procedural memory and learning, making it difficult for the child to automatize the sequence of sounds into words and words into phrases (Hildebrand et al., 2020; Iuzzini-Seigel, 2021; Vhaga-Khadem et al., 2005). From careful review of the kinematic studies, Namasivayam and colleagues (2020) proposed that “speech variability issues in CAS may arise at the level of articulatory synergies (intra-gestural coordination)” (p. 15). For example, Grigos and colleagues (2015) found that children with CAS demonstrate higher lip-jaw spatiotemporal variability with increasing utterance complexity and greater lip aperture variability. Terband et al. (2011) saw that children with CAS had less stable tongue tip-jaw synergy and greater contribution of the lower lip for bilabial closure (Namasivayam et al., 2020). Which one of these underlying deficit theories is correct? It could be all or any of them. As we discover the neuroanatomical and genetic differences, we have learned that there are many potential causes that impact neurodevelopment; thus, these children could have a variety of underlying deficits, leading to the wide range of CAS profiles.

What Do We Mean by Spatiotemporal Parameters of Movement Sequences, and How Does This Impact Speech Accuracy and Prosody? First, let’s break up the term spatiotemporal. This refers to “space” and “timing”— in other words, the exact movement of the tongue, jaw, lips, and soft palate with the correct timing of each movement. Watching a video of the vocal tract movement during speech or singing using MRIs and electropalatography allows us to appreciate more greatly what this entails. Studies using electropalatography have shown that children with CAS do not develop the more finely tuned speech movements with the specificity and precision that typically developing children do (Gibbon, 1999).

1.  Understanding Childhood Apraxia of Speech   15

Core Characteristics of CAS The ASHA 2007 technical report was the first publication to provide a list of core deficits to differentiate CAS from other SSDs. These core features include the following: 1. Inconsistent errors on consonants and vowels in repeated productions of syllables or words 2. Disordered prosody lengthened and disrupted coarticulatory transitions between sounds and syllables 3. Inappropriate prosody, especially in the realization of lexical stress Although these characteristics are indicative of the underlying deficit of impaired motor planning and programming, the report provided a note of caution stating, “these features are not proposed to be the necessary and sufficient signs of CAS” (ASHA CAS Technical Report, 2007, Section Definitions of CAS). These signs will vary depending on the age of the child, comorbid diagnoses, severity of the disorder, and the task given. For example, a young child with severe CAS may only have a few sounds in their phonetic repertoire, making it unlikely they will be able to demonstrate any of these characteristics. Since this report was written, researchers continue their efforts to better define and specify criteria for a diagnosis of CAS (Iuzzini-Seigel, 2021; Iuzzini-Seigel et al., 2015, 2017; Murray et al., 2015; Strand, 2020). The diagnostic checklists are similar to each other, while the exact criteria may vary. For example, while a diagnosis of CAS with Strand’s 10-point checklist required any combination of at least four of the 10 features listed, Iuzzini-Seigel (2021) uses a list of 11 characteristics and recommends that a child needs to present with five or more of the features, in addition to inconsistent errors, three times each in three different contexts. Iuzzini-Seigel et al. (2015) assist the reader by operationally defining each of the characteristics. It can also be helpful to separate the characteristics into segmental characteristics and suprasegmental characteristics, as many SLPs have better training in listening for segmental (speech sound errors) than for suprasegmental errors (related to lexical stress and smooth coarticulation). For this reason, it is strongly encouraged to video-record the child’s assessment, as it can be difficult to accurately judge all the characteristics in real time. See Table 1–4 for a list of widely accepted characteristics of CAS. Inconsistency of errors (i.e., inconsistent errors on consonants and vowels in repeated productions of syllables or words) is listed as the top core characteristic for differential diagnosing of CAS but was not included in the table, as it requires a longer explanation. Inconsistency of errors refers to the variability in speech production, and it can be measured several different ways (Betz & Stoel-Gammon, 2005; Iuzzini & Forrest, 2010; Iuzzini-Seigel et  al., 2017; Terband et al., 2019). For example, inconsistency can be measured based on multiple productions of the same whole word or phrase, as in the case of token-to-token inconsistency, or it can be calculated by measuring how inconsistent the speech sounds are from productions of different words and phrases. More details on how to obtain inconsistency measures will be provided in Chapter 2. When relying on inconsistent errors as a measure for differential diagnosis, it is important to note that the developmental stage of the child’s motor speech system will be a factor; thus,

16   Here’s How to Treat Childhood Apraxia of Speech

Table 1–4.  Diagnostic Criteria Frequently Used for CAS With Operational Definitions and Examples Divided Into Segmental and Suprasegmental Characteristics

Characteristic

Definition

Examples (including diacritical markersa as appropriate)

Segmental Characteristics 1.  Vowel errors

Vowel substitutions or distortions that are not due to dialect. The vowel does not sound like a prototypical production and may sound like it is in between two vowels.

Substitution errors: /bɑt/ for /bæt/ “bat” /bɑk/ for /baɪk/ “bike” Distortion errors: Shortened vowels as in /dæ̆dɪ̆/ for /dædi/ “Daddy”

2. Consonant distortion

A consonant that is recognizable but not produced accurately.

Lateralized /s/ and /z/ as in /drɛʪəʫ/ for “dresses”

3.  Intrusive schwa

A schwa (epenthesis) that is added between consonants or at the end of a word

Addition of schwa in a cluster: /bəlu/ for “blue” Schwa between syllables: /bækɘpæk/ for “backpack” Schwa at the end of a word: /maɪjɘ/ for “my” /mænə/ for “man”

4.  Voicing errors

A sound is produced as its voiced cognate. This could also include productions that appear to be in between voicing categories, when it is not expected, as in an intervocalic stop, as in “little.”

Substitution: /bɪk/ for “pick” Partially voiced: /t̬ɑp/ for “top”

5. Difficulty achieving initial articulatory configurations or transitional movement gestures

Initiations of words and sounds are difficult for the child to produce and may sound lengthened or uncoordinated. The child may also produce lengthened or disrupted coarticulatory gestures when transitioning from one sound or syllable to the next.

A delay in timing as the back of the tongue is raised with a lengthened release for /k/, as in /…kːæn..aɪ/ for “Can I?”

6. Groping

There are visible trial-and-error movements of the articulators prior to speaking.

Child’s lips protrude, retract, and then open prior to saying “out.”

1.  Understanding Childhood Apraxia of Speech   17

Table 1–4.  continued

Characteristic

Definition

Examples (including diacritical markersa as appropriate)

7. Increased difficulty with multisyllabic words

There are disproportionately more errors as the number of syllables increase as compared to words with fewer syllables.

Child can say “axe” and “dent” but says /æ.skɪ.dən/ for “accident.”

8. Resonance or nasality disturbance

Nasal sounds are hyponasal or denasal / /͊ (not acoustic energy from the nose) and/or oral sounds are hypernasal / ˜/ (too much acoustic energy from the nose).

Child is hyponasal on /m/ and /n/ but hypernasal on /b/ and /d/—in this example, / m͊ aɪ.b̃rʌ.θɚz..n͊eɪm.ɪz.d̃æn/ for “My brother’s name is Dan.”

*Nasal resonance errors tend to be inconsistent for children with CAS if there is no coexisting dysarthria or velopharyngeal insufficiency. Suprasegmental Characteristics 9. Syllable segregation 10. Slow rate and/or slow DDK rates

11.  Stress errors

Brief or lengthy pause between syllables that are not linguistically appropriate.

/fæn..tæs..tɪk/ for “fantastic”

Speech rate is not typical.

/kːæːnː..aːɪːhːæːvːwːʌːn/ for “Can I have one?”

*Decreased rate of speech is more noticeable when the child is attempting the correct articulatory configurations, or when asked to repeat a novel sound sequence like “pataka.” When stress is placed on the wrong syllable or when all syllables receive equal stress. *Weak syllable deletion may also be included in this category (Strand & McCauley, 2019)

DDK rates are slower than age-matched norms.

Equal stress on each syllable: /ˈbeɪˈbi/ for /ˈbeɪˌbi/ “baby” /ˈbjuˈtiˈful/ for /ˈbjuˌɾɪfəl/ “beautiful” 

For “beautiful,” note that the vowels may be altered due to stressing the unstressed syllables. Misplaced stress: /ˈpoˌlis/ for /ˌpəˈlis/ “police” Weak syllable deletion: /næ.nə/ for “banana”

Note.  Adapted from “Reliance on Auditory Feedback in Children With Childhood Apraxia of Speech,” by J. Iuzzini-Seigel, T. P. Hogan, A. J. Guarino, and J. Green, 2015, Journal of Communication Disorders, 54, 32–42, https:// doi.org/10.1016/j.jcomdis.2015.01.002 a See Appendix 2–G for common diacritics used for disordered speech.

18   Here’s How to Treat Childhood Apraxia of Speech

the stimuli will need to be appropriate for the child’s age and ability. For example, young typically developing children will have greater variability in their speech productions as they are rapidly acquiring speech. Conversely, a young child with CAS may show little variation because of having a restricted phonemic repertoire. As the typically developing child matures, their system becomes more stable and less variable, but as the child with CAS obtains more sounds and syllable shapes, their speech becomes more variable. Part of the challenge of diagnosing CAS is the lack of a gold standard assessment or a single pathognomonic characteristic that is indicative of CAS. Many of the characteristics listed in Table 1–4 may be present in other SSDs but not to the same extent as they are in CAS. In addition, researchers vary on how many of these characteristics need to be observed, which characteristics need to be observed, and in how many conditions they need to be observed to make a diagnosis of CAS. For this reason, it is helpful to summarize how likely it is to see the characteristics frequently listed as core features of CAS in comparison to other SSDs. Table 1–5 provides a summary of the literature reviewed by Iuzzini-Seigel and Murray (2017) as it pertains to the occurrence of frequently listed characteristics of CAS compared to other SSDs. Murray and colleagues (2015) employed a discriminant function analysis model to determine which combination of characteristics was the most indicative of CAS. Combined measures from syllable segregation (noticeable gaps between syllables), lexical stress matches, percentage phonemes correct (PPC) from a polysyllabic picture naming task, and articulatory accuracy on the sequential movement repetition task /pʌtʌkʌ/ reached 91% diagnostic accuracy when compared to expert diagnosis differentiating CAS from dysarthria and other SSDs. Given that salient characteristics can change over time, it is important to note that the participants in their study ranged in age from 4 to 12 years, and the mean age was 5.8. Syllable segregation, low PPC, and poor lexical stress matches were also observed in one child with ataxic dysarthria. Of all the different types of dysarthria, ataxic dysarthria can be the most difficult one to differentiate from CAS due to some of the overlapping characteristics. However, children with ataxic dysarthria will have more noticeable motor control challenges of the physiological speech subsystems (e.g., respiration, phonation, resonance, and articulation) (Allison & Hustad, 2018). Benway and Preston (2020) compared multisyllabic word production in children with CAS to children with other types of SSDs between 7 and 17 years of age. The resulting features that differentiated the two groups were slightly different from what Murray and colleagues (2015) found. For example, percentage of consonants correct on multisyllabic words did not differentiate children with CAS from children with other SSDs. Characteristics that were statistically different included voicing change errors (e.g., prevocalic voicing errors), percentage of structurally correct words (i.e., correct syllable shapes), percentage stress correct, and percentage of full syllable deletion. Authors noted that their results may have differed from earlier research on multisyllabic word repetition error types that help distinguish CAS from other SSDs due to the age of their participants among other reasons. Varied results from different studies highlight several factors one should be aware of when reading the research. First, children with CAS compose a heterogenous group; second, salient characteristics change over time; and third, methods used for elicitation and data analysis and participant criteria vary greatly. Each study builds on information from the last, which allows us to learn more about this multifaceted disorder.

Table 1–5.  A Research Summary of Core Characteristics Observed in CAS Compared to Other SSDs Other Speech Sound Disorders (artic/phono/dysarthria)

Characteristic

CAS

Vowel errors

100% of children with CAS presented at least one vowel error on the GFTA-3.b 100% of preschoolers with CAS and 90% of school-age children had vowel errors.c

10% of children with speech delay had vowel errors on the GFTA-3.b 8% of preschoolers with isolated speech sound disorders and language disorders (SL) and 0% of school-age children with SL had vowel errors.c

Consonant distortions

*Consonant distortions are not a pathognomonic characteristic.a

Children and adults may have consonant distortions due to structural differences, dysarthria, and other SSDs.a

Intrusive schwa

75% of school-age children with CAS evidenced schwa insertion during a standardized articulation test.b

30% of school-age children with speech delay evidenced schwa insertion during a standardized articulation test.b

Voice onset time (VOT)/voicing

85% of school-age children with CAS had voicing errors.b

40% with SD had voicing errors.b

Groping

54% of preschool-age children had articulatory groping, and 29% had nonspeech oral groping.d

0% of children with other SSDs showed evidence of groping.d

*This behavior is not seen in all children with CAS and is not necessary for a diagnosis of CAS.a Resonance

50% of children with CAS had disturbance in resonance.b

10% of children with speech delay had disturbance in resonance.b *Disordered resonance can also occur in dysarthria and velopharyngeal insufficiency.

Syllable segregation

75% of children with CAS had syllable segregation.b

30% of children with phonological disorder had syllable segregation.b

Decreased rate

50% of school-age children with CAS had decreased rate.b

20% of children with speech delay had a decreased rate.b *Slow rate is also indicative of dysarthria.

DDK

Children with CAS only averaged 48% accuracy over two trials of /pʌtʌkʌ/, and children with CAS + dysarthria averaged 24% accuracy.d

Children with other SSDs averaged 76% over two trials.d

Stress errors

52% of children with CAS had inappropriate sentential stress.a

10% of children with SD had inappropriate sentential stress.a

10% had accurate lexical stress matches on polysyllabic words.d

67% of children with other SSDs (submucous cleft, phono disorder and dysarthria) had accurate lexical stress matches on polysyllabic words.d continues

19

20   Here’s How to Treat Childhood Apraxia of Speech

Table 1–5.  continued

Characteristic

CAS

Inconsistency

Children with CAS produced inconsistent errors when repeating “Buy bobby a Puppy” repeated five times.b Children with CAS had a consonant substitute inconsistency percentage (CSIP) of over 24%.e

a

Other Speech Sound Disorders (artic/phono/dysarthria) Children with other speech delays were consistent in their productions.b Children with phonological or articulatory disorders had a CSIP score of below 21%.e

Data from “Speech Assessment in Children With Childhood Apraxia of Speech,” by J. Iuzzini-Seigel and E. Murray, 2017, Perspectives of the ASHA Special Interest Groups, 2(2), 47–60, https://doi.org/10.1044/persp2.SIG2.47

b

Data from “Speech Inconsistency in Children With Childhood Apraxia of Speech, Language Impairment, and Speech Delay: Depends on the Stimuli,” by J. Iuzzini-Seigel, T. Hogan, and J. Green, 2017, Journal of Speech, Language, and Hearing Research, 60, 1194–1210, https://doi.org/10.1044/2016_JSLHR-S-15-0184

c

Data from “School-Age Follow-Up of Children With Childhood Apraxia of Speech,” by B. Lewis, L. A. Freebairn, A. J. Hansen, S. K. Iyengar, and H. G. Taylor, 2004, Language, Speech, and Hearing Services in Schools, 35(2), 122–140, https://doi.org/10.1044/0161-1461(2004/014)

d

Data from “Differential Diagnosis of Children With Suspected Childhood Apraxia of Speech,” by E. Murray, P. McCabe, R. Heard, and K. J. Ballard, 2015, Journal of Speech, Language, and Hearing Research, 58(1), 43–60, https://doi.org/10.1044/2014_JSLHR-S-12-0358

e

Data from “A Comparison of Oral Motor and Production Training for Children With Speech Sound Disorders,” by K. Forrest and J. Iuzzini-Seigel, 2008, Seminars in Speech and Language, 29(4), 304–311, https://doi.org/​10.1055/​ s-0028-1103394

Suspected CAS in Children Before the Age of Three Years Infants and toddlers who are not reaching the expected communication milestones in a timely manner may be suspected of having CAS and are unlikely to present with many of the characteristics listed earlier due to lack of vocalizations. For years, what was known about early communication skills in children later diagnosed with CAS was obtained by anecdotal reports (Highman et al., 2008). These children were often described as less vocal, having a limited sound repertoire, decreased babbling, simple syllable shapes, and limited suprasegmental patterns, with a later emergence of first words. In addition, it was reported they may experience a loss of words or phonemes, have difficulty with feeding, and have delayed fine and gross motor skills (Davis & Velleman, 2000; Highman et al., 2008). Highman et al. (2008) did a retrospective study comparing parent reports of children in three groups: (1) typically developing (TD), (2) suspected CAS (sCAS), and (3) specific language impairment (SLI). There were 20 children in each group, and they ranged from 3 to 5 years of age when their parents filled out the questionnaire. Their results supported previously reported observations, but there was some overlap of characteristics between children with CAS and children with SLI. Results are summarized in Table 1–6. Although it is helpful to know the red flags for CAS in the child’s developmental history, it is important to be aware of the similarities and differences for the purpose of making a correct diagnosis. In addition, 45% of children with SLI and sCAS were reported to have feeding problems compared to 15% of TD children. However, only 20% of children with SLI and 10% of TD

1.  Understanding Childhood Apraxia of Speech   21

Table 1–6.  Verbal and Motor Milestones of Typically Developing (TD) Children, Children With Specific Language Impairment (SLI), and Suspected CAS (sCAS) Typically Developing

SLI

sCAS

Vowel noises

4.9 months

8.2 months

8.2 months

Reduplicated babble

7.2 months

10.1 months

11.0 months

Variegated babble

9.2 months

12.2 months

Did not occur

First word

9.2 months

13.0 months

14.0 months

Two-word combinations

14.6 months

27.0 months

33.3 months

Milestone Verbal Milestones

Nonverbal/Motor Milestones Smiled

6.9 weeks

16.8 weeks

8.6 weeks

Crawling

9.1 months

9.1 months

7.5 months

First steps unaided

11.7 months

12.5 months

13.6 months

Note.  Adapted from “Retrospective Parent Report of Early Vocal Behaviours in Children With Suspected Childhood Apraxia of Speech (sCAS),” by C. Highman, N. Hennessey, M. Sherwood, and S. Leitao, 2008, Child Language Teaching & Therapy, 24(3), 285–306, https://doi.org/10.1177%2F0265659008096294

children were reported to have dribbling issues compared to 45% of the children with CAS. When asked if their children babbled as much as, more than, or less than other children, 80% of parents of children with CAS and 70% of parents of children with SLI reported their children babbled less than other children, compared to only 5% of TD children (Highman et al., 2008). Overby et al. (2019) analyzed home videos of infants and toddlers (birth to age 2 years) later diagnosed with CAS (LCAS) (n = 7), children with speech sound disorders (LSSD) (n = 5), and TD children (n = 5) to compare volubility, consonant emergence, and syllabic structure from birth to 2 years of age. Volubility refers to the amount of vocalization produced regardless of type. Early vocalizations were coded as nonresonant vocalizations (sounds that cannot be transcribed with the International Phonetic Alphabet, such as vegetative sounds) and resonant vocalizations (speechlike, including vowels and consonants, babbling, and words). Although children with LSSD had less volubility than TD children, children in the LCAS group had significantly less volubility of resonant utterances and consonants and higher volubility of nonresonant utterances than the children in the LSSD and TD groups. Examination of the diversity of resonant consonants and features of consonants revealed a similar trend, where children with LCAS had significantly less diversity of consonants and diversity of place and manner features than the other two groups. A summary of potential red flags for a later diagnosis of CAS from the findings of Overby et al. (2019) and Overby and Caspari (2015) are listed in Box 1–1. When we consider the long-range implications of decreased variegated babble; reduced phonetic repertoire of sound, place, manner and voicing contrasts; and reduced syllable sequences, one can theorize that delays in these areas will not bode well for the child. If

22   Here’s How to Treat Childhood Apraxia of Speech

Box 1–1.  Early Vocal Characteristics Observed in Infants and Toddlers Later Diagnosed With CAS 1. Limited vocalization during the child’s first 2 years 2. Lack of a resonant consonant by 12 months 3. Acquisition of three or fewer resonant consonants between 8 and 16 months old 4. Acquisition of five or fewer resonant consonants between 17 and 24 months of age 5. Dependency on bilabials, alveolars, stops, and nasals with a paucity of velars or posterior sounds before age 2 years 6. Productions of stops and nasals over a more diverse manner repertoire (e.g., fricatives and affricates) 7. Use of mostly vowels at 13–18 months with little use of simple consonant vowel sequences or more complex syllable structures 8. Lack of voiceless consonants between birth and 24 months of age

experience is the chief architect of the brain, the lack of vocalizations will negatively impact the cognitive-linguistic and motor aspects of phonology. This, in turn, will lead to less accurate phonological representations that affect language and literacy development (Miller et al., 2019; Overby et al., 2020; Velleman, 2011), which brings us to our next section.

Language and Literacy The interaction of motor speech development, language, and literacy is fascinating and complex and will continue to keep researchers actively engaged for years to come. As we learn more about genetic variants that impact neurodevelopment and neural substrates and pathways implicated in CAS, one can see why a child with CAS is likely to be challenged in more than one area of motor and linguistic development. Hence, it is not surprising that as the child with CAS becomes more intelligible, we often begin to notice the co-occurrence of an expressive language disorder. Children with CAS frequently present with syntactic errors (e.g., word sequencing errors, omission of function words, and reduced mean length of utterance) and morphological errors (e.g., omission of plural “s” or past tense “ed” markers) (Crary, 1993; Ekelman & Aram, 1983; Murray et al., 2019). One might be inclined to believe that the linguistic errors are solely due to the child’s motor speech challenges, since children with CAS have difficulty with complex syllable shapes and produce more errors as the utterance length increases (e.g., adding “s” to denote plurality or possession could increase the syllable shape complexity). However, some linguistic errors are not related to motor speech (e.g., gender pronoun errors [“she” for he], incorrect auxiliary substitutions [“is” for are], and omission of verbs in sentences) and may persist in children with CAS beyond the age at which these features should have been attained (Ekelman & Aram, 1983; Murray et al., 2019). Research has also shown that children with CAS are at higher risk for difficulties in areas related to literacy, such as rhyming, word attack, word identification, spelling, phonological perception, phonological discrimination, and phonological memory (ASHA, 2007a). When

1.  Understanding Childhood Apraxia of Speech   23

a child has CAS or a persistent SSD, in addition to a language impairment, they are at even higher risk for having difficulties with reading and writing (Cabbage et al., 2018; Lewis et al., 2004; Miller et al., 2019). Lewis and colleagues (2004) conducted a follow-up of preschoolers with CAS and found that even when the children improved in articulation, they continued to have difficulties with syllable sequencing, nonsense word repetition, language, reading, and writing. Miller and colleagues (2019) assessed school-age children and adolescents (7–18 years) with sCAS and SSDs without CAS and compared measures on performance IQ, oral language, phonological awareness, rapid automatic naming, diadochokinetic rates, single word articulation, and multisyllable and nonsense word repetition. Results indicated that children with sCAS with language and phonological awareness deficits had poorer reading outcomes. Motor speech deficits and speech sound production also had an impact on reading outcomes, but to a lesser degree (Miller et al., 2019). The studies cited in this section represent a fraction of the research done in this area. Results of numerous studies looking at the relationship of CAS and linguistic-based disorders highlight the need for a comprehensive assessment of motor speech skills, in addition to language, phonological awareness, and literacy skills, when CAS is suspected.

Related Areas of Concern Additional areas of concern are observed in some children with CAS. Parents may report problems with early feeding, clumsiness, or behavior challenges. The SLP may be the first person to observe delays in gross and fine motor coordination and/or sensory processing. These areas of related concern are described in more detail next.

Early Feeding Difficulties Some children with CAS exhibit motor planning challenges during eating and drinking (Highman et al., 2008). They may have trouble coordinating their chewing and swallowing or their sucking and swallowing, causing them to eat slowly; stuff too much food in their mouths; hold the food for a long time before swallowing; or suck, suck, suck and then gulp their liquid, rather than using a rhythmic suck/swallow/breathe pattern. Management of mixed textures also may be challenging for some children with CAS. Feeding difficulties often are resolved by the time a child with suspected CAS is brought to the SLP for an initial screening or evaluation. Information about the child’s prior feeding challenges can be obtained from a thorough case history. If feeding difficulties currently exist, it is important to determine if the underlying nature of feeding challenges in children with CAS is related to planning the coordinated oral movements for feeding tasks or to the child’s muscular strength.

Gross and Fine Motor Children with CAS often present with fine and gross motor delays (ASHA, 2007a), and many researchers have noted a relationship between developmental coordination disorder (DCD) and CAS (Duchow et al., 2019; Hodge, 1998; Iuzzini-Seigel, 2019). DCD is a neurodevelopmental disorder in which a child’s motor coordination difficulties significantly interfere with activities of daily living or academic achievement. These

24   Here’s How to Treat Childhood Apraxia of Speech

children typically have difficulty with fine and/or gross motor skills, with motor performance that is usually slower, less accurate, and more variable than that of their peers. (Zwicker et al., 2012, p. 573)

It is estimated that 5% to 6% of school-age children have DCD (Zwicker et al., 2012). When Duchow et al. (2019) examined results of standardized DCD parent questionnaires of 35 children with sCAS, they found that 49% of the children had possible DCD (pDCD). This supported their hypothesis of there being a significantly higher number of children with CAS having pDCD than the general population. Iuzzini-Seigel (2019) examined fine and gross motor performance among 10 children with CAS, 16 children with SSD, and 14 TD children. The movement components assessed included manual dexterity, aiming and catching, and balance. When comparing the three groups, TD performed the best, followed by children with SSD, and then children with CAS. Eight of the 10 children with CAS obtained a standard score (SS) of 5 or lower, where the mean SS is 10, which indicates significant movement difficulty. When the children were compared based on the presence of a co-occurring language impairment (LI; CAS only = 3, CAS + LI = 7, SSD only = 10, SSD + LI = 6, and 14 TD children), children with CAS + LI had the poorest performance in all three areas. All seven of the children with CAS + LI received a SS of 5 or below, whereas only one of the three children with CAS performed this poorly. Although the sample size in this study was relatively small, the results highlight the importance of the additive risk factors that come with a diagnosis of CAS and LI, versus CAS alone. Research on concomitant fine and gross motor disorders also points to the importance of a team evaluation that includes occupational therapists and physical therapists.

Sensory Processing It is also not uncommon for children with CAS to have some challenges with sensory processing (Newmeyer et al., 2009). This can include the ability to appropriately respond to and integrate auditory, vestibular, tactile, gustatory (taste), olfactory, visual, and/or proprioceptive input. Although parents and health care providers frequently see evidence of these issues in children with neurodevelopmental disorders such as ADHD, ASD, and CAS, the terms used to include it in a diagnosis vary and are not without controversy (Arky, n.d.; Newmeyer et al., 2009). For example, the diagnosis of Sensory Processing Disorder (SPD), often used by occupational therapists (OTs), may be listed on a child’s report, but it is not in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) because it is not recognized as a distinct medical diagnosis. However, “sensory problems” is included as one of the criteria for the ASD diagnosis (Arky, n.d.). Hence, it is more prudent to describe the sensory issues a child exhibits than to use the term SPD. Keeping that in mind, it can certainly be helpful to obtain a sensory profile for children who appear to struggle in multiple areas, such as attention, behavior, and communication, since how they perceive their environment can influence how they respond in therapy. SLPs are wise to integrate activities that promote focus and motivation by considering the client’s sensory preferences and aversions. Incorporating OT input on how to adapt activities to meet the sensory needs of the child, while working on the child’s speech and language skills can be quite beneficial. Assessments and sensory profile checklists, which are further discussed in Chapter 2, can be helpful in identifying the areas in which a child exhibits difficulty.

1.  Understanding Childhood Apraxia of Speech   25

Newmeyer and colleagues (2009) examined 38 children ages 3 to 10 years with sCAS using the Sensory Profile (Dunn, 1999). The Sensory Profile uses a parent/caregiver questionnaire and Likert scale to look at the areas of (a) sensory processing, (b) modulation, and (c) behavior and emotional responses, which are further broken down into other areas. Results indicated that the children with sCAS had significant differences in area (a) auditory, visual, touch, and multisensory processing; area (b) modulation of movement affecting activity level and sensory input affecting emotional responses; and area (c) behavioral outcomes of sensory processing. Factor cluster scores also revealed a significant difference in the areas of sensory seeking, emotionally reactive, oral sensory sensitivity, and inattention/distractibility.

Social-Emotional Considerations Although research has looked at the social-emotional impact of speech and language disorders on children and adults in general, only a few studies have delved more into this concern for children, adolescents, and adults with CAS (Cassar et al., 2022; Lewis et al., 2021; Rusiewicz et al., 2018; Tarshis et al., 2020). In addition, Farinelli Allen and Babin (2013) and Rusiewicz et al. (2018) examined the social-emotional impact on the parent or caregiver of a child with CAS, as well. Tarshis and colleagues (2020) explore how communication challenges in CAS might impact social competencies in young children, as these young children are more apt to miss out on early opportunities to grow socially. Many parents of children with CAS fear that their children will not make friends when they go to school due to the isolation that comes with not being understood. This article takes a proactive approach to suggesting ways of implementing therapy to address both speech and social goals, which are discussed in Chapters 8 and 9. Rusiewicz et al. (2018) examined the functional implications of CAS from the parent perspective. Forty parents of children ages 3 to 16 years with CAS were given two Likert-scale questionnaires and four open-ended questions about their personal experiences of living with a child with CAS. The majority of the parents (92%) reported a personal emotional reaction to their child being difficult to understand with feelings that ranged from frustration and sadness to heartbreak. Parents also reported that their children commented on feeling sad (33%), commented on feeling frustrated (22%), wished to be understood (22%), were asked why they had difficulty with speech production (11%), and expressed anger (11%). In addition, parents believed their child’s speech impairment had a negative effect on peer interactions (42%), caused avoidance of situations (32.5%), affected play and play dates (27.5%), and decreased their participation in school and church activities (20%). Clinical recommendations to address these issues included creating online or face-to-face support networks for families impacted by CAS, empathizing with parents’ stressors and anxiety related to their role as caregiver, and providing resources for professional support when possible. As part of an ongoing longitudinal study, Lewis and colleagues (2021) examined the psychosocial outcomes of adolescents with a history of CAS and compared them to peers with histories of SSD only and SSD with language impairment. The psychosocial assessment battery included self-report and parent-report measures that looked at a wide range of mental health conditions, such as externalizing problems (e.g., aggression and destructive behavior), internalizing problems (e.g., anxiety, depression, withdrawal, somatic symptoms), ADHD, inattention, social problems, and thought problems (e.g., obsessive thoughts, self-harm, hallucinations, nervous twitching, strange behavior, or ideas). The most common areas in the borderline/

26   Here’s How to Treat Childhood Apraxia of Speech

clinical range noted by the parents included social problems (41%), inattention (35%), and hyperactivity (24%), where children with histories of CAS self-reported social problems (29%), thought problems (29%), and internalizing problems (29%). Authors concluded that “adolescents with histories of CAS may experience more social problems, hyperactivity, and thought problems than adolescents with histories of milder SSD” (Lewis et al., 2021, p. 2578). Working with adolescents can be challenging regardless of there being a communication disorder or not. This study is a good reminder to monitor the client’s mental health and realize that behavioral issues are often signs of needing additional help. Cassar and colleagues (2022) examined the long-term consequences of CAS in adulthood. They looked at self-reported measures of speech, language, and literacy and the psychosocial impacts using the Brief Fear of Negative Evaluation Scale-Revised (BFNE-R) and the State-Trait Anxiety Inventory (STAI ). In addition, they obtained speech samples from 25% of the participants. On average, participants reported elevated levels of state anxiety (i.e., anxiety triggered by a stressful situation) and trait anxiety (i.e., anxiety due to a person’s predisposition to react anxiously to a situation) when compared to normative data. In addition, 75% of respondents reported limited social interactions, 69% reported teasing or bullying, and 50% reported they avoided social functions because of their CAS. From the speech samples and self-reported measures, authors gleaned that many of the adults had ongoing segmental and suprasegmental errors. They concluded that both psychosocial effects and speech errors appeared to persist for adults with CAS. Consistent with prior research (Lewis et al., 2021; Rusiewicz et al., 2018; Tarshis et al., 2020), these findings stress the need for SLPs to be monitoring the mental health of their clients and be proactive in locating the psychosocial supports needed for optimal adjustment to the client’s communication disorder. This is addressed further in Chapter 9.

Using the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) to Guide Assessment and Treatment of Children With CAS When choosing assessment tools, treatment goals, and ways of measuring progress, it is important to keep in mind the ICF-CY framework. This framework reminds the practitioner that it is imperative to have functional outcome measures that will ensure improved participation in all aspects of the child’s life. The ICF-CY offers a conceptual framework and a common language and terminology for recording problems manifested in infancy, childhood, and adolescence involving functions and structures of the body, activity limitations and participation restrictions, and environmental factors important for children and youth (WHO, 2007, p. xii). The ICF-CY (WHO, 2007) is derived from the International Classification of Functioning, Disability and Health (ICF) (WHO, 2001). It was designed to be compatible with the ICF and provide more detailed information relevant to youth below the age of 18 years. It allows the person working with the child to focus on the interaction of how the health condition impacts the function of the body and how that, in turn, limits the child’s participation in the environment they are in. Table 1–7 provides examples of the main areas under each category. Consider how these areas interact with one another. Children with similarly severe CAS may have different levels of participation based on their environmental and personal factors.

1.  Understanding Childhood Apraxia of Speech   27

Table 1–7.  ICF-CY Components, Descriptions of Each Component, and Examples ICF-CY Component

Description*

Examples

Health Condition/ Health Status

Disorder or Disease

1. CAS 2.  Expressive language disorder 3. ASD

Functioning & Disability Body Functions & Structures

Physical, physiological, and cognitive processes that underlie a function. Deficits at any of these levels are impairments.

Impaired • Speech motor planning and programming • Language • Social communication

Activity

The integrated functional activity for which the body structures and mind are used. Deficits at this level are limitations.

Decreased • Intelligibility • Communication skills • Pragmatic skills

Participation

The integrated functional activity to accomplish tasks in daily life and participate in society. Deficits at this level are restrictions.

Restricted • Interaction with peers and turntaking during games • Ability to answer questions appropriately in class • Interpersonal interactions and social relationships

Contextual Factors Environmental Factors

Attitudes and beliefs of the settings the child is in, such as school, home, clubs, and faith community.

• School provides appropriate services and there is a culture that does not tolerate bullying. • Supportive family, but financially struggling • Club members are not educated or understanding of neurodiversity.

Personal Factors

Attitude, beliefs, coping skills of the individual

• Low self–esteem • Easily frustrated • Able to laugh at their mistakes and works hard to overcome obstacles

*Descriptions of ICF–CY components were adapted from “Predicting Intelligibility: An Investigation of Speech Sound Accuracy in Childhood Apraxia of Speech,” by K. Skoog and E. Maas, 2020, CommonHealth, 1, 44–56, https://doi.org/10.15367/ch.v1i2.397

Conversely, children with different diagnoses and levels of severity may have similar levels of participation based on their own environmental and personal factors. The beauty of the ICF-CY is that although we may not be able to remove the health condition, we can improve

28   Here’s How to Treat Childhood Apraxia of Speech

the child’s activity and participation by making accommodations (e.g., providing augmentative and alternative communication, paraprofessionals, and increased time to respond) and decreasing the level of impairment (e.g., increasing speech intelligibility, language skills, and joint attention). We can also improve participation by addressing the contextual factors such as increasing understanding and inclusiveness of the people in the child’s environment (e.g., school, home, community centers) and building resilience, persistence, and coping skills, in the child, themself.

References Allison, K., & Hustad, K. (2018). Data-driven classification of dysarthria profiles in children with cerebral palsy. Journal of Speech, Language, and Hearing Research, 61, 2837–2853. https://doi.org/10.1044/2018_ JSLHR-S-17-0356 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https:// doi.org/10.1176/appi.books.9780890425596 American Speech-Language-Hearing Association. (n.d.). Speech sound disorders: Articulation and phonology [Practice portal]. https://www.asha.org/Practice-Por​ tal/Clinical-Topics/Articulation-and-Phonology/ American Speech-Language-Hearing Association. (2007a). Childhood apraxia of speech [Position statement]. https://www.asha.org/policy/PS2007-00277/ American Speech-Language-Hearing Association. (2007b). Childhood apraxia of speech [Technical report]. http://static.crowdwisdomhq.com/asha/47​ 35​%20Technical%20Report.pdf Arky, B. (n.d.). The debate over sensory processing: A look at the dispute over whether sensory symptoms constitute a disorder, and whether treatment works. Child Mind Institute. https://childmind.org/article/ the-debate-over-sensory-processing/ Benway, N. R., & Preston, J. L. (2020). Differences between school-age children with apraxia of speech and other speech sound disorders on multisyllabic repetition. Perspectives of the ASHA Special Interest Groups 2, 5, 794–808. https://doi.org/10.1044/2020_ PERSP-19-00086 Cabbage, K., Farquharson, K., Iuzzini-Seigel, J., Zuk, J., & Hogan, T. (2018). Exploring the overlap between dyslexia and speech sound production deficits. Language, Speech, and Hearing Services in Schools, 49, 774–786. https://doi.org/10.1044/2018_LSHSS-DY​ SLC-18-0008 Cassar, C., McCabe, P., & Cumming, S. (2022). “I still have issues with pronunciation of words”: A mixed methods investigation of the psychosocial and speech effects of childhood apraxia of speech in adults.

International Journal of Speech-Language Pathology. https://doi.org/10.1080/17549507.2021.20​18496 Chilosi, A. M., Lorenzini, I., Fiori, S., Graziosi, V., Rossi, G., Pasquariello, R., Cipriani, P., & Cioni, G. (2015). Behavioral and neurobiological correlates of childhood apraxia of speech in Italian children. Brain and Language, 150, 177–185. https://doi.org/10.1016/j​ .bandl.2015.10.002 Crary, M. A. (1993). Developmental motor speech disorders. Singular. Davis, B. L., & Velleman, S. L. (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers. Infant-Toddler Intervention, 10(3), 177–192. Dodd, B. (2021). Re-evaluating evidence for best practice in paediatric speech-language pathology. Folia Phoniatrica et Logopaedica, 73, 63–74. https://doi.org/​ 10.1159/000505265 Duchow, H., Lindsay, A., Roth, K., Schell, S., Allen, D., & Boliek, C. (2019). The co-occurrence of possible developmental coordination disorder and suspected childhood apraxia of speech. Canadian Journal of Speech-Language Pathology and Audiology, 43(2), 81–93. Dunn, W. (1999). Sensory Profile. Pearson. Eising, E., Carrion-Castillo, A., Vino, A., Strand, E., Jakielski, K., Scerri, T., . . . Fisher, S. (2019). A set of regulatory genes co-expressed in embryonic human brain is implicated in disrupted speech development. Molecular Psychiatry, 24(7), 1065–1078. https://doi​ .org/10.1038/s41380-018-0020-x Ekelman, B. L., & Aram, D. M. (1983). Syntactic findings in developmental verbal apraxia. Journal of Communication Disorders, 16(4), 237–250. https:// doi.org/10.1016/0021-9924(83)90008-4 Farinelli Allen, L., & Babin, E. A. (2013). Associations between caregiving, social support, and well-being among parents of children with childhood apraxia of speech. Health Communication, 28(6), 568–576. https://doi.org/10.1080/10410236.2012.703120

1.  Understanding Childhood Apraxia of Speech   29 Fiori, S., Guzzetta, A., Mitra, J., Pannek, K., Pasquariello, R., Cipriani, P., . . . Chilosi, A. (2016). Neuroanatomical correlates of childhood apraxia of speech: A connectomic approach. NeuroImage: Clinical, 12, 894–901. https://doi.org/10.1016/j.nicl.2016.11.003 Fiori, S., Pannek, K., Podda, I., Cipriani, P., Lorenzoni, V., Franchi, B., . . . Chilosi, A. (2021). Neural changes induced by a speech motor treatment in childhood apraxia of speech: A case series. Journal of Child Neurology, 36(11). 958–067. https://doi​.org/10.1177 %2F08830738211015800 Fisher, S., Vargha-Khadem, F., Watkins, K., Monaco, A., & Pembrey, M. E. (1998). Localisation of a gene implicated in a severe speech and language disorder. Nature Genetics, 18, 168–170. https://doi.org/​ 10.1038/ng0298-168 Forrest, K., & Iuzzini-Seigel, J. (2008). A comparison of oral motor and production training for children with speech sound disorders. Seminars in Speech and Language, 29(4), 304–311. https://doi.org/10.10​55/​ s-0028-1103394 Fowler, K. (2017). “An extended family with a dominantly inherited speech disorder” (1990), by Jane A. Hurst et al. Embryo Project Encyclopedia (2017, March 23). http://embryo.asu.edu/handle/10776/11455 Gibbon, F. E. (1999). Undifferentiated lingual gestures in children with articulation/phonological disorders. Journal of Speech, Language, and Hearing Research, 42(2), 382–397. https://doi.org/10.1044/jsl​ hr.4202.382 Graham, S. A., & Fisher, S. E. (2015). Understanding language from a genomic perspective. Annual Review of Genetics, 49, 131–160. https://doi.org/10.1146/ annurev-genet-120213-092236 Grigos, M. I., Moss, A., & Ying, L. (2015). Oral articulatory control in childhood apraxia of speech. Journal of Speech, Language, and Hearing Research, 58(4), 1103–1118. https://doi.org/10.1044/2015_JSLHR-​ S-13-0221 Groenen, P., Maassen, B., Crul, T., & Thoonen, G. (1996). The specific relation between perception and production errors for place of articulation in developmental apraxia of speech. Journal of Speech, Language, and Hearing Research, 39(3), 468–482. https:// doi.org/10.1044/jshr.3903.468 Highman, C., Hennessey, N., Sherwood, M., & Leitao, S. (2008). Retrospective parent report of early vocal behaviours in children with suspected Childhood Apraxia of Speech (sCAS). Child Language Teaching and Therapy, 24(3), 285–306. https://doi.org/​ 10.1177%2F0265659008096294 Hildebrand, M. S., Jackson, V. E., Scerri, T. S., Van Reyk, O., Coleman, M., Braden, R. O., . . . Morgan, A. (2020). Severe childhood speech disorder: Gene

discovery highlights transcriptional dysregulation. Neurology, 94(20), e2148–e2167. https://doi.org/​10​ .1212/wnl.0000000000009441 Hodge, M. M. (1998). Developmental coordination disorder: A diagnosis with theoretical and clinical implications for developmental apraxia of speech. Language Learning and Education, 5, 8–11. https:// doi.org/10.1044/lle5.2.8 Hurst, J., Baraitser, M., Auger, E., Graham, F., & Norell, S. (1990). An extended family with a dominantly inherited speech disorder. Developmental Medicine & Child Neurology, 32, 347–355. https://doi.org/​10.11​ 11/j.1469-8749.1990.tb16948.x Iuzzini, J., & Forrest, K. (2010). Evaluation of a combined treatment approach for childhood apraxia of speech. Clinical Linguistics & Phonetics, 24, 335–345. https://doi.org/10.3109/02699200903581083 Iuzzini-Seigel, J. (2019). Motor performance in children with childhood apraxia of speech and speech sound disorders. Journal of Speech, Language, and Hearing Research, 62, 3220–3233. https://doi.org/10.10​44/​ 2019_JSLHR-S-18-0380 Iuzzini-Seigel, J. (2021). Procedural learning, grammar, and motor skills in childrenwith childhood apraxia of speech, speech sound disorder, and typically developing speech. Journal of Speech, Language, and Hearing Research, 64, 1081–1103. https://doi.org/​ 10.10​44/2020_JSLHR-20-00581 Iuzzini-Seigel, J., Hogan, T., & Green, J. (2017). Speech inconsistency in children with childhood apraxia of speech, language impairment, and speech delay: Depends on the stimuli. Journal of Speech, Language, and Hearing Research, 60, 1194–1210. https://doi​.org/ ​10.1044/2016_JSLHR-S-15-0184 Iuzzini-Seigel, J., Hogan, T. P., Guarino, A. J., & Green, J. (2015). Reliance on auditory feedback in children with childhood apraxia of speech, Journal of Communication Disorders, 54, 32–42. https://doi.org/​ 10.1016/j.jcomdis.2015.01.002 Iuzzini-Seigel, J., & Murray, E. (2017). Speech assessment in children with childhood apraxia of speech. Perspectives of the ASHA Special Interest Groups, 2(2), 47–60. https://doi.org/10.1044/persp2.SIG2.47 Kadis, D., Goshulak, D., Namasivayam, A., Pukonen, M., Kroll, R., DeNil, L., . . . Lerch, J. (2014). Cortical thickness in children receiving intensive therapy for idiopathic apraxia of speech. Brain Topography, 27, 240–247. https://doi.org/10.1007/s10548-013-0308-8 Laffin, J. J., Raca, G., Jackson, C. A., Strand, E. A., Jakielski, K. J., & Shriberg, L. D. (2012). Novel candidate genes and regions for childhood apraxia of speech identified by array comparative genomic hybridization. Genetics in Medicine, 14(11), 928–936. https:// doi.org/10.1038/gim.2012.72

30   Here’s How to Treat Childhood Apraxia of Speech Lehman Blake, M., & Hoepner, J. K. (2023). Clinical neuroscience for communication disorders: Neuroanatomy and neurophysiology. Plural Publishing Lewis, B., Avrich, A., Freebairn, L., Hansen, A., Suches­ ton, L., Kuo, I., . . . Stein, C. (2011). Literacy outcomes of children with early childhood speech sound disorders: Impact of endophytes. Journal of Speech, Language, and Hearing Research, 54(6), 1628–1643. https://doi.org/10.1044/1092-4388(2011/10-0124) Lewis, B., Benches, P., Tag, J., Miller, G., Freebairn, L., Taylor, G., Iyengar, S., & Stein, C. (2021). Psychosocial comorbidities in adolescents with histories of childhood apraxia of speech. American Journal of Speech-Language Pathology, 30, 2572–2588. https:// doi.org/10.1044/2021_AJSLP-21-00035 Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar, S. K., & Taylor, H. G. (2004). School-age follow up of children with childhood apraxia of speech. Language, Speech, and Hearing Services in Schools, 35(2), 122– 140. https://doi.org/10.1044/0161-1461(2004/014) Liégeois, F., Morgan, A. T., Connelly, A., & VarghaKhadem, F. (2011). Endophenotypes of FOXP2: Dysfunction within the human articulatory network. Official Journal of the European Paediatric Neurology Society, 15, 283–288. https://doi.org/10.1016/j.ejpn​ .2011.04.006 Marion, M., Sussman, H., & Marquardt, T. (1993). The perception and production of rhyme in normal and developmentally apraxic children. Journal of Communication Disorders, 26(3), 129–160. https://doi.org/​ 10.1016/0021-9924(93)90005-U Marquardt, T., Sussman, H., Snow, T., & Jacks, A. (2002). The integrity of the syllable in developmental apraxia of speech. Journal of Communication Disorders, 35(1), 31–49. https://doi.org/10.1016/S00219924(01)00068-5 Miller, G., Lewis, B., Benches, P., Freebairn, L., Tag, J., Budge, K., . . . Stein, C. (2019). Reading outcomes for individuals with histories of suspected childhood apraxia of speech. American Journal of SpeechLanguage Pathology, 28, 1432–1447. https://doi.org/​ 10.1044/2019_AJSLP-18-0132 Morgan, A. T. (2020). Severe childhood speech disorder: Gene discovery highlights transcriptional dysregulation. Neurology, 94(20), e2148–e2167. https://doi​ .org/10.1212/WNL.0000000000009441 Morgan, A., Lauretta, M., & Feldman, H. (2021). CAS and genetics: Causes and testing, Apraxia-Kids. https://www.apraxia-kids.org/wp-content/uploads/​ 2021/08/CAS-and-Genetics-Article.pdf Morgan, A., & Webster, R. (2018). Aetiology of childhood apraxia of speech: A clinical practice update for paediatricians. Journal of Paediatrics and Child Health, 54(10), 1090–1095. https://doi.org/10.1111/jpc.14150

Morley, M., Court, D., & Miller, H. (1954). Developmental dysarthria. British Medical Journal, 1, 8. https:// doi.org/10.1136/bmj.1.4852.8 Murray, E., McCabe, P., Heard, R., & Ballard, K. J. (2015). Differential diagnosis of children with suspected childhood apraxia of speech. Journal of Speech, Language, and Hearing Research, 58(1), 43–60. https:// doi.org/10.1044/2014_JSLHR-S-12-0358 Murray, E., Thomas, D., & McKechnie, J. (2019). Comorbid morphological disorder apparent in some children aged 4–5 years with childhood apraxia of speech: Findings from standardized testing. Clinical Linguistics & Phonetics, 33(1–2), 42–59. https://doi​ .org/​10.1080/02699206.2018.1513565 Namasivayam, A., Coleman, D., O’Dwyer, A., & van Lieshout, P. (2020). Speech sound disorders in children: An articulatory phonology perspective. Frontiers in Psychology, 10, 1–16. https://doi.org/10.3389/ fpsyg.2019.02998 Newmeyer, A., Aylward, C., Akers, R., Ishikaway, K., Grether, S., deGrauw, T. . . . White, J. (2009). Results of the sensory profile in children with suspected childhood apraxia of speech. Physical & Occupational Therapy in Pediatrics, 29(2), 203–218. https:// doi​.org/10.1080/01942630902805202 Overby, M., Belardi, K., & Schreiber, J. (2020). A retrospective video analysis of canonical babbling and volubility in infants later diagnosed with childhood apraxia of speech. Clinical Linguistics & Phonetics, 34(7), 634–651. https://doi.org/10.1080/02699206​ .2019.1683231 Overby, M., & Caspari, S. S. (2015). Volubility, consonant, and syllable characteristics in infants and toddlers later diagnosed with childhood apraxia of speech: A pilot study. Journal of Communication Disorders, 55, 44–62. https://doi.org/10.1016/j.jcom​ dis.2015.04.001 Overby, M. S., Caspari, S. S., & Schreiber, J. (2019). Volubility, consonant emergence, and syllabic structure in infants and toddlers later diagnosed with childhood apraxia of speech, speech sound disorder, and typical development: A retrospective video analysis. Journal of Speech, Language, and Hearing Research, 62, 1657–1675. https://doi.org/10.1044/2019_JSLHR-S-​ 18-0046 Peter, B., Matsushita, M., & Raskind, W. (2012). Motor sequencing deficit as an endophenotype of speech sound disorder: A genome-wide linkage analysis in a multigenerational family. Psychiatric Genetics, 22(5), 226–234. https://doi.org/10.1097/YPG.0b013​ e328353ae92 Potter, N. L., Kent, R. D., & Lazarus, J. A. C. (2009). Oral and manual force control in preschool-aged children: Is there evidence for common control? Jour-

1.  Understanding Childhood Apraxia of Speech   31 nal of Motor Behavior, 41(1), 66–82. https://doi.org/10​ .1080/00222895.2009.10125919 Potter, N., Nievergelt, Y., & Shriberg, L. (2013). Motor and speech disorders in classic galactosemia. Journal of Inherited Metabolic Disorders Reports, 11, 31–41. https://doi.org/10.1007/8904_2013_219 Rosenbek, J., & Wertz, R. (1972). A review of fifty cases of developmental apraxia of speech. Language, Speech, and Hearing Services in Schools, 1, 23–33 https://doi​ .org/10.1044/0161-1461.0301.23 Rusiewicz, H., Maize, K., & Ptakowski, T. (2018). Parental experiences and perceptions related to childhood apraxia of speech: Focus on functional implications. International Journal of Speech-Language Pathology, 20, 569–580. https://doi.org/10.1080/17549507.2017​ .1359333 Shriberg, L. D., Aram, D., & Kwiatkowski, J. (1997a). Developmental apraxia of speech: I. Descriptive and theoretical perspectives. Journal of Speech, Language, and Hearing Research, 40, 273–285. https://doi.org/​ 10.1044/jslhr.4002.273 Shriberg, L. D., Aram, D. M., & Kwiatkowski, J. (1997b). Developmental apraxia of speech II. Toward a diagnostic marker. Journal of Speech, Language, and Hearing Research, 40(2), 286–312. https://doi.org/10​ .1044/jslhr.4002.286 Shriberg, L. D., Kwiatkowski, J., & Mabie, H. L. (2019). Estimates of the prevalence of motor speech disorders in children with idiopathic speech delay. Clinical Linguistics & Phonetics, 33(8), 679–706. https://doi​ .org/​10.1080/02699206.2019.1595731 Shriberg, L. D., Strand, E., Jakielski, K. J., & Mabie, H. L. (2019). Estimates of the prevalence of speech and motor speech disorders in persons with complex neurodevelopmental disorders. Clinical Linguistics and Phonetics, 33(8), 707–736. https://doi.org/10.1080/​ 02699206.2019.1595732 Skoog, K., & Maas, E. (2020). Predicting intelligibility: An investigation of speech sound accuracy in childhood apraxia of speech. CommonHealth, 1(2), 44–56. https://doi.org/10.15367/ch.v1i2.397 Strand, E. A. (2020). Dynamic temporal and tactile cueing: A treatment strategy for childhood apraxia of speech. American Journal of Speech-Language Pathology, 29(1), 30–48. https://doi.org/10.1044/2019_AJ​ SLP-19-0005 Strand, E. A., & McCauley, R. J. (2019). Dynamic Evaluation of Motor Speech Skill (DEMSS) manual. Brookes. Tarshis, N., Garcia Winner, M., & Crooks, P. (2020). What does it mean to be social? Defining the social landscape for children with childhood apraxia of speech. Perspectives of the ASHA Special Interest Groups, 5(4), 843–852. https://doi.org/10.1044/2020_PERSP19-00116

Terband, H., Maassen, B., van Lieshout, P., & Nijland, L. (2011). Stability and composition of functional synergies for speech movements in children with developmental speech disorders. Journal of Communication Disorders, 44(1), 59–74. https://doi.org/10.1016/j​ .jcomdis.2010.07.003 Terband, H., Namasivayam, A., Maas, E., van Brenk, F., Mailed, M., Diepeveen, S., . . . Maassen, B. (2019). Assessment of childhood apraxia of speech: A review/ tutorial of objective measurement techniques. Journal of Speech, Language, and Hearing Research, 62, 2999–3032. https://doi.org/10.1044/​2019_JSLHR-SCSMC7-19-0214 Vargha-Khadem, F., Gadian, D., Copp, A., & Mishkin, M. (2005). FOXP2 and the neuroanatomy of speech and language. Nature Reviews of Neuroscience, 6, 131–138. https://doi.org/10.1038/nrn1605 Vargha-Khadem, F., Watkins, K. E., Price, C. J., Ashburner, J., Alcock, K. J., Connelly, A., . . . Passingham, R. E. (1998). Neural basis of an inherited speech and language disorder. Neurobiology, 95(21), 12695– 12700. https://doi.org/10.1073/pnas.95.21.12695 Velleman, S. L. (2011). Lexical and phonological development in children with childhood apraxia of speech — A commentary on Stoel-Gammon’s “relationships between lexical and phonological development in young children.” Journal of Child Language, 38(1), 82–86. https://doi.org/10.1017/s03050​ 00910000498 Velleman, S., & Mervis, C. (2011). Children with 7q11.23 duplication syndrome: Speech, language, cognitive, and behavioral characteristics and their implications for intervention. Perspectives on Language Learning and Education, 18(3), 108–116. https://doi​ .org/10.1044/lle18.3.108 Velleman, S., & Strand, K. (1994). Developmental verbal dyspraxia. In J. E. Bernthal & N. W. Bankson (Eds.), Child phonology: Characteristics, assessment, and intervention with special populations (pp. 110– 139). Thieme Medical Publishers. World Health Organization. (2001). International classification of functioning, disability and health (ICF). https:// www.who.int/classifications/international-classifi​ cation-of-functioning-disability-and-health World Health Organization. (2007). International classification of functioning, disability and health: Children and youth version (ICF-CY). https://apps.who.int/iris/ handle/10665/43737 Zwicker, J., Missions, C., Harris, S., & Boyd, L. (2012). Developmental coordination disorder: A review and update. European Journal of Paediatric Neurology, 16, 573–581. https://doi.org/10.1016/j.ejpn.2012.05​ .005

CHAPTER

2

Assessment and Differential Diagnosis of Childhood Apraxia of Speech

A

s discussed in Chapter 1, children with childhood apraxia of speech (CAS) often have difficulties with expressive language, phonological awareness, speech perception, and literacy (Iuzzini-Seigel, 2019; Lewis et al., 2004; Murray et al., 2021; Zuk et al., 2018). In addition, they may exhibit dysarthria (Murray et al., 2015; Shriberg et al., 2019) and developmental coordination disorder (Duchow et al., 2019; Iuzzini-Seigel, 2019). Given the complexity of CAS, the overlapping characteristics with other speech sound disorders, and the likelihood of co-occurring disorders, differential diagnosis often requires a battery of assessments. Recent research on genetics and brain imaging further illustrates that CAS is often just one part of the puzzle to tease out in the midst of other potential challenges. The purpose of this chapter is to guide the reader with the most up-to-date assessments that can be used in the clinic, while accounting for the child’s stage of development and potential co-occurring disorders. Our goal is to be as informed as possible regarding the nature of the sensorimotor planning deficit (in relation to any other deficits, such as cognitive, linguistic, and motor execution) (Strand, 2017).

Who Diagnoses CAS? The American Speech-Language-Hearing Association (ASHA) Ad Hoc Committee on Apraxia of Speech in Children (ASHA, 2007) suggests that “A well-trained speech-language pathologist with specific experience in pediatric speech sound disorders, including motor speech disorders [emphasis added], is the appropriate professional to assess and diagnosis CAS” (ASHA Childhood Apraxia of Speech Technical Report, p. 53). Although other professionals working with a pediatric population — such as pediatricians, pediatric neurologists, or psychologists — may suspect apraxia, the speech-language pathologist (SLP) with training in sensorimotor speech disorders is specifically qualified to make a differential diagnosis and determine a course of action for treatment.

33

34   Here’s How to Treat Childhood Apraxia of Speech

Conceptualizing Assessment When a child is referred for an assessment for a speech delay or disorder, it is helpful to first conceptualize the basic elements of what is necessary for speech production. This is important for caregivers to understand as well. Few people fully appreciate the multiple processes that need to be intact to utter an intelligible meaningful utterance. Figure 2–1 may be useful when explaining the assessment outcomes to the parent, especially when there are cognitive and linguistic components involved. A child can have decreased verbal output for a multitude of reasons. Hence, there is a lot to factor in during the assessment process for the SLP to determine which deficits are impacting the child the most and what strengths are available to build communicative success. Table 2–1 provides an overview of the key areas of assessment and why it is pertinent for a child suspected to have CAS. Each area is discussed in greater detail throughout the course of the chapter.

A Developmental Lens How one assesses CAS is dependent on the child’s age, other diagnoses, and the child’s ability to imitate. ASHA’s Childhood Apraxia of Speech Practice Portal (n.d.) suggests that making a definitive diagnosis of CAS prior to age 3 years is difficult due to the challenge of obtaining a sufficient speech sample. Hence, if characteristics of difficulty with sensorimotor planning and programming for speech are observed prior to age 3 years, ASHA recommends using the phrases “CAS cannot be ruled out,” “signs are consistent with problems in planning the movements required for speech,” or “suspected to have CAS.” Additionally, diagnosing CAS before age 3 years can be problematic because the core characteristics of CAS do not easily differentiate children with CAS from other children. In other words, prior to age 3 years, even a typically developing child may present with inconsistent errors, vowel errors, and lexical stress errors (e.g., weak syllable deletion) (Iuzzini-Seigel & Murray, 2017; Kent & Rountrey, 2020; Masso et al., 2018). The child may also not be able or willing to attempt imitation. There is research, however, to guide the SLP to look for early signs of CAS (Overby & Caspari, 2015; Overby et al., 2019, 2020).

Assessment Recommendations for Children Under Age Three Years Case History Obtaining a case history and observing the child’s vocalizations and communicative behaviors will assist in obtaining a good clinical picture of the toddler with delayed speech development. Given that CAS tends to be overdiagnosed (Shriberg et al., 2017), it is helpful to know which etiologies, vocal characteristics, and communicative behaviors are consistent with CAS versus other disorders. Clark and Baas (2021) remind the SLP to be mindful of the prevalence of CAS versus other speech sound disorders, as to not overdiagnose CAS. When children are younger, there are more overlapping characteristics between CAS and other causes for reduced verbal communication. It is helpful to remember that CAS accounts for less than 3% of speech sound

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   35

Figure 2–1.  Basic conceptualization of what is necessary for speech. (Adapted from Caruso & Strand, 1999; Strand, 2020.)

Table 2–1.  Key Areas of Assessment for Determining Relative Contribution of CAS to the Communication Disorder Assessment

Purpose

Hearing evaluation

Make sure hearing acuity is optimal for speech development and that middle ear health is monitored.

History of feeding, prelinguistic, and early linguistic skills

A careful case history can yield information that leads to a hypothesis about the child’s communication disorder based on family history, early vocal behaviors, sensorimotor skills, and play skills. (See Table 1–6 for developmental milestones of children with CAS versus typically developing children and the description of early developing speech that follows for reference.)

Informal observations during play or conversation (depending on the child’s age)

It is not uncommon for the child to look very different from what was expected based on prior reports. Thus, watching the child during play will guide the SLP’s assessment protocol in terms of what will be appropriate for the child’s speech, language, cognition, attention, and social skills.

Receptive and expressive language assessment

Children with CAS typically have higher receptive skills than expressive skills; however, they may have delays in both. Assessing receptive and expressive language skills will provide information about the child’s current language functions and determine if areas other than speech skills need to be addressed in treatment. Assessment of receptive language skills also may provide a window into the child’s cognitive development. If receptive language skills are severely delayed, a referral for cognitive testing may be appropriate.

Structural-functional examination

This is important for ruling out any overt structural deficits (e.g., cleft palate, severe ankyloglossia) as well as deficits in strength, speed, range of motion, or coordination (i.e., dysarthria). See Tables 2–4 through 2–10.

Maximum performance tasks

Assessment of the five subsystems for speech production (articulation, phonation, respiration, resonance, and prosody) will allow the clinician to observe the physiological support needed for speech. Weakness and/ or incoordination in any of these areas is indicative of dysarthria.

Nonverbal praxis examination

Nonverbal oral apraxia may or may not accompany CAS, but it is helpful to know if the child is able to follow nonverbal oral sensorimotor directions when providing instruction for articulatory placement. See Tables 2–11 and 2–12.

Articulation assessment with phonological analysis of speech errors

Assessment of articulation and phonology allows the clinician to see if the sound errors are limited to just a few sounds, as is the case with an articulation disorder or if there is a consistent pattern of errors (e.g., fronting, cluster reduction, initial consonant deletion), indicating a phonological delay or disorder. A child with CAS may also have a phonological disorder.

Independent and relational sound inventory

An independent inventory of the child’s speech refers to the sounds and syllable shapes the child is making independent of the adult target, where a relational analysis is one that compares the child’s sounds and syllable shapes to the adult target to see what they are missing or have in error. For children with CAS, their independent inventory typically has more sounds than their relational inventory.

36

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   37

Table 2–1.  continued Assessment

Purpose

Vowel assessment

Unlike children with phonological error patterns only (i.e., phonological delays/disorders), children with CAS often present with vowel errors in addition to errors on consonants. Special attention needs to be paid to the production of vowels during the articulation assessment and other speech samples, as these errors could easily go missed since vowel production is given less consideration in most standardized articulation tests. In addition, assessment of vowel errors is often overlooked in the training of SLPs. See Chapter 5 for additional information on assessment of vowels.

Prosody

Informal probes of the child’s lexical and sentential stress patterns, use of pitch and loudness variation to signal linguistic differences, and observations of linguistically inappropriate pauses between sounds and syllables are all elements of prosody that can be impacted in CAS. (See Chapter 5 for additional information on assessment of prosody.)

Assessment of sensorimotor speech skills

A sensorimotor speech evaluation is designed to assess the child’s ability to plan and program sequences of sounds by systematically increasing phonetic complexity, syllable shape, syllable length, and phrase length. The goal is to see where the child breaks down and if the child improves with cueing, such as saying the target word simultaneously while watching the clinician and responding to tactile cues. This element of the examination is crucial for choosing appropriate targets for treatment.

Phonological awareness and literacy skills

Children with CAS often have difficulty with phonological awareness, reading, and writing. Even after their sensorimotor speech skills have improved, there may still be delays in literacy. Assessment of phonological awareness and literacy skills will help determine if these skills need to be addressed in addition to or in the context of speech and language therapy.

Speech perception

Children with CAS and a co-occurring language impairment can have weak acoustic-phonetic representation, which can impact the ability to produce target phonemes.

disorders in preschool children, while developmental articulation and phonological disorders account for over 80% of speech sound disorders (Shriberg et al., 2019). In addition, it is not uncommon to see children with autism spectrum disorder (ASD) given a diagnosis of CAS, as they both present with reduced communication during the early stages of development. The prevalence of ASD is currently 1 in 44 (Maenner et al., 2021), much higher than CAS, which only occurs in 1 to 2 children per 1,000 (Shriberg et al., 2019). Since pediatricians are encouraged to screen for ASD at age 18 and 24 months (Lipkin & Macias, 2020) it would be appropriate for the SLP to inquire if the child had received the ASD screening during their well-child visit, especially if ASD is suspected. If the child did not receive a screening and ASD is suspected, an ASD checklist, such as the Autism Parent Screen for Infants (APSI; Sacrey et al., 2018), for children ages 6 to 24 months could be useful for determining if a referral for further

38   Here’s How to Treat Childhood Apraxia of Speech

testing is warranted. In addition, Autism Navigator (https://autismnavigator.com/) provides the 16 by 16 online screener for ASD. If the parent notices eight or more of these 16 early signs by age 16 months, it is recommended they ask their doctor for a full diagnostic evaluation. Examples of these early signs include the child rarely sharing enjoyment or interests with the parent, not responding to their name, and little or no imitation of others or pretending. (See Table 2–25 for the URL.) Although there are no standardized screening tools or assessment protocols for infants and toddlers that can provide a definitive diagnosis of CAS, there is research that supports observations that lead one to suspect CAS, such as reduced speech-like vocalizations, limited phonetic inventory of consonants and vowels, late emergence of first consonants and first words, and predominant use of simple syllable shapes (Davis & Velleman, 2000; Overby & Caspari, 2015; Overby et al., 2019). The case history questions in Appendix 2–A and the observation checklist in Appendix 2–B will guide and support the SLP’s evaluation of the toddler. To get a better sense of the child’s functioning in their home environment, it helps to ask the parent to walk you through a typical day with their child. This can bring to light information that we do not always get from the standard questionnaire. For example, the parent may share how difficult it is to get the child fed and dressed due to sensory issues or how their child does not vocalize as much as the other children in their play group. Providing a way for the parent to share their story in this manner can also help facilitate a stronger sense of connection and gives the SLP a chance to validate the feelings the parent may have. In addition to looking for early signs of CAS, the case history should address age of attainment of motor milestones and any concerns about ASD, auditory comprehension, dysarthria, feeding and swallowing, sensory issues, and behavioral concerns (e.g., difficulty getting joint attention, dislikes change in routine, frequent temper tantrums, aggressive behavior, etc.).

Considerations for Internationally Adopted Children One population that is often overlooked when taking a case history are internationally adopted children (IAC). The vast majority of IAC are adopted after age 1 year, and thus the parent may feel there is not much to offer the SLP for diagnostic information on the traditional case history form. However, there are several variables that have been shown to impact the speech, language, social-emotional, cognitive, gross, and fine motor development of IAC that the parent can provide information about. The SLP should inquire about the type of attention the child received prior to adoption. Each country has different standards of care, which can impact the child’s development. Orphanage care varies greatly by region. Some children receive excellent care and services, while others are strained for resources, and children get minimal attention. A general rule of thumb is for every 3 months in an institution, expect 1 month of delay (Jenista, 1997). Some countries have foster care as an option to orphanages or large institutions. Children raised in foster care typically get more attention and language stimulation resulting in reaching developmental milestones at the appropriate times. Some children live in an orphanage prior to being placed in a foster home. It is also possible that the IAC were raised by their biological family and had to be adopted due to the loss of their parents. Although these children often fare better with attachment and development because of the attention they received in early development, the trauma of losing their birth family and being brought to another country needs to be considered.

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   39

The examiner will also want to know if there were any medical diagnoses that the child arrived with. These diagnoses are not always consistent with what is observed at the assessment but can be a good place to start. Some countries over diagnose disorders to make it easier for the country to relinquish the child, while other countries may downplay issues to make the child more likely to be adopted. If there are any medical records that came with the child, it helps to know there are international adoption clinics around the country that specialize in reviewing the adoptees’ records. This is beneficial, as different countries use different terminology, and the international adoption clinic is able to discern the information that the records provide as they know what to expect from each country. In regard to speech and language development, IAC often have delays in their first language due to environmental deprivation (Glennen, 2014). In addition, IAC will go through a quiet period as they transition to their new language. Unless the adopted family speaks the child’s first language, they lose their first language and are usually caught up in their adopted family’s language in 1 to 2 years. Studies done on age of adoption have shown that the younger the age of adoption, the faster the child should be acquiring their new language. Glennen’s (2014) results on age of adoption and time needed exposed to the new language to achieve age-appropriate language skills is provided in Box 2–1. Box 2–2 provides additional resources for internationally adopted children. Table 2–2 gives the SLP an alternative or supplemental developmental history questionnaire that will be more relevant to an adoptive parent than the traditional history forms. Box 2–1.  Amount of Time Exposed to New Language Needed for Acquisition Age at adoption

Time to achieve expected language skills

1–2 years

15 months

3 years

2 years

4 years

3 years

Box 2–2.  Additional Resources for Internationally Adopted Children

Resources Working with Internationally Adopted Children https://www.asha.org/practice/multicultural/intadopt/ Phonemic Inventories and Cultural and Linguistic Information Across Languages https://www.asha.org/practice/multicultural/phono/ International Adoption Clinics https://www.barkeradoptionfoundation.org/sites/default/files/ International%20Adoption%20Medical%20Resources.pdf

40   Here’s How to Treat Childhood Apraxia of Speech

Table 2–2.  Questionnaire for Parents of Internationally Adopted Children (IAC) 1. How old was your child at the time of adoption? 2. Where was your child adopted from? 3. Was your child raised in an orphanage, foster care, or both? 4. Did the child have any time with their birth family prior to adoption? 5. What was the ratio of caregiver to child where your child was raised? 6. What medical diagnoses were you made aware of from the adoption agency? 7. Has your child or their records been reviewed by an international adoption clinic? If so, do you have that report to share? 8. What information did you receive about your child’s speech and language development? 9. Describe the child’s speech and language skill development since joining your family.

Speech and Language Assessment for Children Under Age Three Years A child referred to an SLP at an early age for their lack of speech development is not apt to be at the point where they can participate in a formal articulation assessment. Hence, information from the case history and observations while building rapport during the play portion of the assessment will aid the SLP in checking for signs consistent with characteristics in children who later have a CAS diagnosis. The SLP will want to observe the child interacting with whomever they are most verbal to obtain the child’s sound inventory and syllable shape inventory. Infants and toddlers do not always perform on command, so it may also be helpful to ask the caregiver to bring videos of the child from home. In addition to observing vocalizations and sounds, the SLP will want to note which communicative intents (e.g., request for help, items, activities, and attention, refusing or rejecting items and activities, labeling, describing, commenting, and expressing feelings) and what communication modalities they are using (e.g., gestures, sign, verbal approximations). Appendix 2–B provides a form to record this information and a checklist of the characteristics frequently observed in children later diagnosed with CAS. It is important to note that these observations do not provide a definitive diagnosis. They do, however, indicate the child should receive early intervention. Sometimes families are told to take a “wait and see” approach. If this is the case, the family and/or physician may need additional evidence, encouragement, and support to obtain the appropriate services for their child in a timely manner. Standardized expressive language assessments that require verbal responses will not be reliable measures of nonverbal or minimally verbal children for obvious reasons. In addition to it being too motorically difficult for the child to verbally respond, the parent may try to interpret what the child is saying, which can skew results. When assessing expressive language with a minimally verbal child, the informal observations listed earlier and in Appendixes 2–A and 2–B may reveal more than a test. However, receptive language assessments are especially useful for obtaining a more accurate diagnostic profile of the child’s communication skills.

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   41

Parents often report that their child understands everything and that they just cannot talk. Sometimes this is accurate, but these observations are not necessarily valid and reliable, as the child can give the impression they understand more than they do by following the visual cues and routines that occur in the home rather than actually comprehending the sentences and vocabulary used in the directions. Appropriate language assessments and screenings for the birth to age 3 years population include the following: • Communication and Symbolic Behavior Scales (CSBS) (Prizant & Wetherby, 2003) for ages 8 to 24 months (or up to 72 months if developmental delays are present) • Bayley Scales of Infant and Toddler Development Screening Test (Bayley-4 Screening Test) (Bayley & Aylward, 2019) for ages 16 days to 42 months • Receptive-Expressive Emergent Language Test, Third Edition (REEL-3) (Bzoch et al., 2003) for up to age 3. • MacArthur-Bates Communicative Development Inventories (MB-CDIs) (Fenson et al., 2007) • MB-CDI Words and Features is designed for 8- to 18-month-old children. • MB-CDI Words and Sentences is designed for 16- to 30-month-old children.

The case history provided in Appendix 2–A will alert you to other areas that should be screened (e.g., ASD and cognition, sensory and motor deficits) to assist with making the appropriate referrals. ASD screenings were discussed earlier. Following are examples of screenings for other areas of development: • Hawaii Early Learning Profile (HELP: 0–3) (Parks Warshaw, 2013) assesses cognitive, language, gross motor, fine motor, social-emotional, and self-help in children birth to age 3 years. • Westby’s Symbolic Play Scale (Westby, 1980) for children ages 17 months to 5 years (URL is provided in Table 2–25.) Screening of hearing is also important, but an audiologist will be needed for children too young to respond to play audiometry.

Structural-Functional Exam for Children Under Age Three Years Children under age 3 years may not be able or willing to follow instructions to participate in a formal structural-functional exam, as outlined in Tables 2–5 through 2–12. However, observing the child’s face at rest is feasible and essential for checking to see if there is any dysmorphology that could impact function and/or be associated with a syndrome. It will also be vital to observe if the child is able to breathe at rest with a closed-mouth posture. An open-mouth posture can be indicative of a restricted upper airway (e.g., enlarged adenoid tissue, choanal atresia, deviated septum) and can negatively impact the development of the upper jaw, palate, dental occlusion, and muscles of the tongue. Function of the articulatory structures can be observed during eating, drinking, swallowing, laughing, and giving their parent a kiss. If the child happens to yell and/or cry during the evaluation, this will give you additional information on phonatory and respiratory support. Of course, we do not encourage eliciting these behaviors, but if it happens you can note voice quality, duration of phonation, and ability to vary loudness. Last, to determine function of the velopharyngeal mechanism,

42   Here’s How to Treat Childhood Apraxia of Speech

elicit oral and nasal consonants in syllables (e.g., “pa” or “pop” when popping bubbles and “mama” to get the mother’s attention). Note if there is any nasal emission or nasalizing of oral sounds and if these errors are consistent or inconsistent to discern if the disordered resonance is due to structure, dysarthria, or CAS.

Assessment Report Summary for Children Under Age Three Years The report should provide the SLP’s diagnostic impressions of all areas of development observed and assessed during the evaluation. As previously stated, ASHA recommends using terms like suspected CAS (sCAS) if the child is under age 3 years, has characteristics consistent with CAS but does not have enough. It is not uncommon for parents to want a definitive diagnosis. This is understandable, as it gives them a place to look for help, such as other parents support groups, books, and online resources. At this point of the journey, parents need to be assured that their child is being treated in a manner that addresses all areas of concern to ensure the best outcomes for optimal communication. These little ones are dynamic beings who can change quickly in a period of months. In addition, it can take several therapy sessions to build trust and rapport to see what the child is truly capable of. In addition, there will be more time for dynamic assessment that will allow the SLP and parents to see the techniques the child responds to best. For example, a child with expressive language delay may not need the therapist to hold the toy up to their mouth to see the movement of the articulators to attempt imitation, where the child with a sensorimotor speech disorder will. Explaining these nuances to the parents may help them understand that a more definitive diagnosis will become easier over time.

Assessment for Children Over Age Three Years When children are more capable of imitative tasks and following directions, which typically happens after age 3 years, there are more assessment tools available for the SLP. The next part of this chapter goes through the assessments that can be used for children in preschool through early school age. However, if the child has a developmental delay, is resistant or unable to do some of these tasks, it may be more appropriate to use the tools listed in the previous section. The areas of assessment listed do not have to be completed in any particular order. It is recommended to start in an area in which the child will be successful, such as pointing to pictures for a receptive vocabulary test versus labeling pictures for an articulation test. In addition, not all assessments will be appropriate for all children. For example, if the child is unable to attempt most of the words on a standardized articulation test, move on to the dynamic sensorimotor speech exam with simple syllable shapes and maximal cuing. Last, it can be helpful to set up a visual schedule of the assessments you hope to get through and make a game out of it. One trick is to put the pictures representing the tasks on a treasure map and when they get to the end of the map, they get to pick a prize out of the prize box. Between tasks, the examiner and child can play a mind-reading game where the child gets to put a different colored sticker on each pictured task once it is completed. The examiner is not allowed to look and has to guess which color the child chose. If the examiner gets it wrong, the child gets a point; if the examiner gets it right, the examiner gets a point. Needless to say, the child wins in this scenario, giving the child something to feel good about. Dr. Nancy Potter,

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   43

who came up with this motivator, has managed to assess thousands of children with this little game, so it comes highly recommended.

Case History The case history form provided in Appendix 2–C is appropriate for young children in general; however, as the child enters kindergarten, other questions related to language and early literacy are essential. As mentioned before, it is helpful to ask the parent to walk you through a typical day with their child. This will provide additional insight into how this child’s communication and coping skills are impacting them in their activities of daily living. An example case history form for children preschool age through second grade can be found in Appendix 2–C. For children grades 3 and up, it will be important to ask about the child’s family history of communication and/or learning challenges, therapy history, academic history, how the child copes with having a communication disorder, and what the child enjoys and has strengths in. In regard to their therapy history, we want to know the services they have received (e.g., occupational therapy, physical therapy, speech-language therapy, etc.), when they started receiving services, how often they received services, what were their goals, what therapy techniques they did and did not respond well to, how much progress they made, and what were the results of past assessment reports. For academic history, ask about services the child received and currently receives from the school and for past and present Individualized Education Programs (IEPs).

Hearing Screening All children should receive a hearing screening. Refer to ASHA guidelines on Pure-Tone Screening Procedures provided in the link in Table 2–25. Play audiometry may be needed for conditioning children between 3 and 5 years of age to respond appropriately. Table 2–3 provides basic instructions and an example of a hearing screening form.

Structural-Functional Assessment (SFA) It is not uncommon for SLPs to overlook doing a structural-functional assessment. A study by Murray and colleagues (2015) found that of the 47 participants in their study on differential diagnosis of CAS, three had undiagnosed submucous cleft, and six had dysarthria. This is consistent with a recent study, where the majority (60%) of SLPs surveyed had low or no confidence

Table 2–3.  Basic Hearing Screening Protocol Pure-tone hearing screening in quiet room:  Administer 2+ conditioning trials @ 40 dB HL prior to hearing screen. Limited to four presentations/pure tone. 500 Hz @ 25 dB HL Right Left

1000 Hz @ 20 dB HL

2000 Hz @ 20 dB HL

4000 Hz @ 20 dB HL

44   Here’s How to Treat Childhood Apraxia of Speech

in diagnosing dysarthria and 40% reported they don’t make the diagnosis (Iuzzini-Seigel et al., in press). A cursory SFA should be done on all children with a speech sound disorder, and a more thorough SFA will be necessary for children with suspected neurological deficits and/or craniofacial anomalies. The full structure-function praxis exam is in Appendix 2–D, as well as in the online materials, and can be copied for your use. For the purpose of this chapter, each part is broken down. Table 2–4 illustrates the portion of the exam that provides observation of the structures at rest and a place to comment on relevant history. The examiner is just being Table 2–4.  Assessment of Structures Name: ____________________________________________  Date: __________________  Age: __________ History regarding chewing, drooling, swallowing, oral aversion, sensory issues, TMJ issues, etc.

Structure & Tone (observe at rest)

Structure (STR)

Comments

Within Functional Limits (WFL)

Deviant

Absent

Present

Cranial/facial symmetry Eyes Ears Lips Mandible Dentition Occlusion Tongue (symmetry at rest) Length of lingual frenulum Hard palate Velum Observations Relating to Tone Drooling Open mouth posture

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   45

asked to judge if structures and muscle tone appear within functional limits (WFL) or deviant. If a structure is marked as deviant, a description should be provided in the comments section. When observing structures at rest, note any involuntary movements in addition to structural differences. Although not directly related to speech production, eyes and ears are included in the list to guide the examiner to look for features that often accompany a syndrome. As discussed in Chapter 1, there are several syndromes in which CAS may occur. For example, children with Noonan syndrome, who sometimes present with CAS, often have wide-set eyes and low-set ears. Sometimes these features are subtle at birth and become more apparent as the child grows; hence, they could have been missed by other practitioners. If a child presents with noticeable dysmorphology, they should be referred to a geneticist for further testing. The next portion of this assessment involves the functions of the structures for articulation and resonance and the cranial nerves that innervate them (Table 2–5). This part of the exam allows the SLP to see if there is any evidence of dysarthria. Characteristics of dysarthria include decreased strength, speed, range of motion, and coordination of the muscles needed for speech. There may also be increased or decreased tone. Tone is related to strength, but it is not the same thing. Tone refers to the tension of the muscle at rest. Strength refers to the child’s ability to recruit the muscles during contraction (i.e., not at rest) and is observed during purposeful movement. A child may have low tone, but strength is WFL for speech, which can be seen in children with CAS. If tone is too low (hypotonia) or too high (hypertonia), the muscles will not Table 2–5.  Oral Motor Function (OMF) Section of the Structural Functional Assessment Structure

Tongue-CN XII

Performance

WFL

Mild– Moderately Impaired

Severely Impaired

Protrusion “Stick out your tongue.” Look for deviation to left or right and range of motion (ROM). Elevation “Can you touch your tongue to your nose?” (Or place a tongue depressor over the upper lip and say, “Touch the stick with your tongue.”) Tongue tip should elevate to the upper lip without lower lip/jaw assistance. Tongue wag “Can you move your tongue like mine?” Model tongue movement from corner to corner for three complete back-and-forth sequences. Observe child’s attempt for speed, coordination, and ROM. Lateral tongue strength “I’m going to try to push your tongue. Don’t let me.” With jaw approximately half open, have the child push against tongue depressor on each side. Note resistance. continues

46   Here’s How to Treat Childhood Apraxia of Speech

Table 2–5.  continued Structure

Lips-CN VII Pucker “Say (oo)” Look for symmetry and ROM. Retraction “Say (ee)” Look for symmetry and ROM. Pucker to retraction “Say (oo-ee x 3)” Look for symmetry, ROM, and speed. Strength of lips pressed together “Bite your teeth together. Now press your lips together. I’m going to try to pull your lips apart, but don’t let me.” Apply upward pressure against upper two quadrants and downward pressure against lower two quadrants to check for resistance with a tongue depressor or gloved finger. If any weakness is observed, note which quadrant — upper right (UR), upper left (UL), lower right (LR), lower left (LL). Jaw-CN V Symmetry, ROM, and stability during jaw opening and closing “Open and close your jaw x 2.” Look for smooth movement, symmetry, appropriate excursion, and evidence of jaw sliding. Velum-CN IX and X Velar elevation during sustained “ah” “Say ah for 5 seconds. I’ll tell you when to start and stop.” Look for timing of movement, ROM, symmetry, and endurance. Velar elevation during staccato production of “ha” “Say ha-ha-ha.” Look for timing of movement, symmetry, and ROM.

Performance

WFL

Mild– Moderately Impaired

Severely Impaired

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   47

be able to respond to resistance as well. For example, when the child is told to resist having their tongue pushed to the side with the tongue depressor, a tongue that seems soft and mushy would indicate hypotonia. When assessing these structures, it can be helpful to have a reference of the cranial nerves on hand, as in Figure 2–2. A summary of findings from the structural-functional exam should include observations of symmetry and tone of structures at rest, dysmorphology, and observations of range of motion, symmetry, speed, strength, and coordination during movement tasks. If all structures and function of structures appear WFL, this will be important to note as it decreases the possibility of the speech sound disorder being due to dysarthria or structural differences, such as cleft or a severe malocclusion. Conversely, list anything that appears not to be WFL and how these differences may or may not impact the child’s speech production.

Assessing the Subsystems The next section of the structural-functional exam assesses the subsystems of speech (i.e., respiration, phonation, articulation, resonance, prosody) and how they work together. This is particularly important when differentiating dysarthria from childhood apraxia of speech when a motor speech disorder is suspected (Iuzzini-Seigel et al., in press; Levy et al., 2021). Levy and colleagues (2021) diagnose dysarthria as present when characteristics are observed in at least two of the speech subsystems.

Resonance Table 2–6 provides oral and nasal speech tasks to assess the resonance. SLPs are good at judging if resonance is disordered or not but have difficulty perceiving if the child sounds hypernasal versus hyponasal. To assist with judgment of resonance, use a listening tube or straw going from under one of the client’s nostrils to the listener’s ear, or place a small mirror under the nostrils while the client repeats the following stimuli. If the child is hypernasal, /b/ will sound more like /m/, which the listening tube will make more noticeable. If they have nasal emission, it will be felt through the tube or seen on the mirror as fog. If the child is hyponasal, /m/ will sound more like /b/, and there will be very little acoustic energy coming through the listening tube. Try listening to the differences using this technique on yourself before using it with a child and experiment with being hyponasal, hypernasal, and producing nasal emission to become acquainted with the differences. If the phrases are too difficult, have the child repeat the syllables instead. If resonance is consistently hypernasal or hypernasal with nasal emissions, the child may have dysarthria (velopharyngeal impairment) or insufficient tissue, as in the case of submucous cleft, unrepaired cleft, or a repaired cleft that needs a secondary repair for better closure. If the child is consistently hyponasal, there is most likely an obstruction keeping them from having good airflow through the nose. If it is inconsistent, it is more apt to be due to sensorimotor planning and indicative of CAS. If the child uses glottal stops /ʔ/ in place of /b/, /p/, and /s/ on the stimuli that follow, you will not be able to judge velopharyngeal (VP) function, as the child is bypassing the need to close the VP port. Children with velopharyngeal insufficiency often use this substitution to avoid nasal air escape on oral consonants. However, children with CAS may also use a glottal stop substitution as part of their reduced phonetic repertoire.

48   Here’s How to Treat Childhood Apraxia of Speech

Figure 2–2.  Cranial nerves. (From Neuroanatomy and neurophysiology for speech and hearing sciences, by A. Seikel, K. Konstantopoulos, and D. Drumright, 2020, p. 219, Figure 7–1A. “Source: After view of Carpenter,” 1991. Copyright 2020 by Plural Publishing.)

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   49

Table 2–6. Resonance Normal

Hypernasal

Nasal Emissions

Hyponasal

Buy Bobby a puppy* Pa pa pa Seesaw, Seesaw, Seesaw Sa sa sa Mama made lemonade Ma ma ma Conversational speech *“Buy Bobby a puppy” will also be used later in the assessment to look at inconsistency.

Maximum Performance Tasks for Respiration, Phonation, and Articulation Maximum performance tasks (MPTs) are also part of the structural-functional examination and are useful in determining the relative involvement of dysarthria versus CAS. They are used to “determine the upper limits of the speech-motor capacities of respiration, phonation, and articulation” (Thoonen et al., 1999, p. 5). Assessment of maximum duration of phonation and exhalation allows the clinician to judge the respiratory and phonatory subsystems, while the multiple syllable rate tasks provide a measure to assess articulatory movement speed, coordination, sequencing, and accuracy. Thoonen et al. (1999) were able to differentiate children with spastic dysarthria from children with CAS, children with other speech sound disorders (e.g., articulation and phonological delay/disorder), and children without speech sound disorders based on diadochokinetic (DDK) rates, articulatory accuracy of trisyllabic sequences, and length of maximum phonation duration. Table 2–7 provides the respiration and phonation portions of the exam. The child should be given multiple attempts and models to obtain their maximum performance, especially if they appear reticent about the task. For the maximum exhalation duration (MED) task, instruct the child to take a deep breath, then blow steadily for as long as they can through a standard elbow straw submerged in 5 cm of water in a cup. Tell them to avoid splashing water when they blow bubbles to get a steady airstream. Sometimes children just give it all they have in one or two seconds, which does not give the examiner a true sense of how long they can sustain controlled exhalation. For the maximum phonation duration (MPD), instruct the child to take a deep breath then say /ah/ with a normal volume for as long as they can. These tasks are not standardized, so providing coaching and motivators is encouraged. For example, it could be turned into a contest among the examiner, the parent, and the child, being sure to allow the child to win. Showing your stopwatch or using visual feedback of a real-time waveform on Audacity can help the child see how long they are holding the sound out for, while providing the clinician the time. For younger kids, the Bla Bla Bla app might be fun (Bravo, 2017). The Bla Bla Bla app is free on iPads and iPhones and has a cast of black-and-white drawn characters to choose from. The louder the child is, the larger the character’s mouth gets. The child could be instructed to keep the character’s mouth open as long as possible.

Table 2–7.  Assessment of Respiration and Phonation

Phonation-Respiration Duration

Trial 1

Trial 2

Trial 3

Longest of Three Trials

Maximum exhalation duration (MED) Have a cup of water with a straw positioned so the low end is 5 cm below the surface of the water. You may need to plug the child’s nose to avoid air escape. “Blow through the straw and make bubbles for as long as you can in one breath. I’ll go first.” Maximum phonation duration (MPD) “Say /ah/ for as long as possible. I’ll go first.” If the child is able to produce multisyllable utterances, note the number of syllables the child can say in one breath group and if the child appears to be running out of breath by the end of the sentence or taking a breath in linguistically inappropriate places.  

Phonation-CNX Observations of Phonatory Quality and Control

Normal

Abnormally High or Low Pitch

Reduced Pitch Range

Strained/ Strangled

Breathy

Rough

Tremor/ Flutter/ Pitch Instability

Sustained Phonation* “Say /ah/ steadily for as long as you can. I’ll go first.” Pitch Range “Sing ah, then go as low as you can. Sing ah again and then go as high as you can. I’ll go first.” Spontaneous Speech Observe the child’s pitch range and voice quality during a connected speech sample. *You can note your observations of sustained phonation from the last task, rather than having the child sustain phonation again.

50

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   51

When interpreting results from the maximum phonation duration and exhalation duration tasks, compare them to normative data. Table 2–8 provides norms for children ages 3 to 12 years based on 160 typically developing children (Potter, unpublished data). Reduced exhalation and phonation duration can be indicative of dysarthria, especially when a strained or breathy voice quality is present and DDK rates are reduced. The ability to vary pitch may be reduced for children with CAS, as well as dysarthria; however, it will be more difficult for the child with dysarthria when phonation and respiration are involved. Using an app like Voice Analyst that provides real-time feedback for pitch may help in eliciting a wider pitch range for children with CAS, as it provides a visual target.

Articulation-DDK Task The last portion of the structural-functional exam is the DDK task, the maximum performance task for articulation. DDK rates are calculated for two different types of tasks: (a) the alternate movement rate (AMR) task, where the client repeats the same syllable multiple times, as in /pʌpʌpʌpʌpʌ/; and (b) the sequential movement rate (SMR) task, as in /pʌtʌkʌ/. DDK rates are calculated using a time-by-count measurement (Fletcher, 1972), where you calculate syllables per second by dividing the number of repetitions produced by the number of seconds it took to produce them. The child may be instructed to say as many repetitions of the stimuli as fast as they can for 5 seconds. If they produced 20 syllables in that time, they would have a DDK rate of four syllables per second. Conversely, you could determine the amount of time used to produce a set number of repetitions. For example, the child is timed on how long it takes to produce seven repetitions. The calculation is the same in terms of dividing the number of repetitions by the amount of time it took. For a more representative rate, remove the first production and last production of the repetitions. For example, if the child produced seven repetitions in an SMR task, calculate syllables per second on the middle five productions. If they produced five repetitions in an AMR task, remove the first and last /pʌtʌkʌ/ (Potter, 2004). Table 2–8.  Normative Data on Maximum Phonation Duration (MPD) and Maximum Exhalation Duration (MED) Based on 20 Males and 20 Females Per Age Group Ages in Years

MPD Mean (SD) in Seconds

MED Mean (SD) in Seconds

3–4

3.45 (1.23)

6.08 (2.61)

5–7

11.65 (4.09)

11.13 (6.00)

8–9

14.23 (4.96)

13.72 (6.18)

10–12

15.77 (6.02)

17.55 (7.75)

Note. Adapted from “Developmental Outcomes in Duarte Galactosemia,” by G. S. Carlock, T. Fischer, M. E. Lynch, N. L. Potter, C. D. Coles, M. P. Epstein, . . . J. L. Fridovich-Keil, 2019, Pediatrics, 143(1), p. e20182516; Oral/ speech and manual motor development in preschool children (Publication No. 3155158), by N. L. Potter, 2004 [Doctoral dissertation, University of Wisconsin–Madison], ProQuest Dissertations and Theses Global.

52   Here’s How to Treat Childhood Apraxia of Speech

To prepare for the DDK task, you will need a stopwatch and an audio recorder. Alternatively, you can do the recording on any free sound editing software, like Audacity. This is efficient and provides more accurate results. Figure 2–3 provides example waveforms of typical speech and disordered speech during repetitions of /pʌtʌkʌ/. Each burst represents a syllable, and the time is visible on the x-axis above the waveform. In example A (typical speaker’s production), there are 32 syllables produced over 5 seconds, yielding a DDK of 6.4 syllables a second. Note that the waveform is fairly rhythmic. In example B, the speaker has a reduced

A

B Figure 2–3.  A. Waveforms representing /pʌtʌkʌ / being repeated multiple times over 5 seconds by a speaker with typically developing speech. B. A speaker with CAS + dysarthria.

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   53

rate of 1.4 syllables a second, and the production is dysrhythmic. This is more indicative of a child with a sensorimotor speech disorder. Table 2–9 provides an example of the recording form for calculating the DDK rates. Table 2–10 provides comparative data from a compilation of multiple studies for children without speech disorders (Kent et al., 2021). The ranges represent the lowest mean DDK rate to the highest DDK rate reported in these studies, with outliers removed from averages and ranges. Table 2–9.  Diadochokinetic (DDK) Calculation Form DDK

Trial 1

Trial 2

Trial 3

Highest DDK Rate of the Three Trials

/pʌ/

_____ syllables/

_____ syllables/

_____ syllables/

= ____ syll/sec

_____ seconds

_____ seconds

_____ seconds

= ____ syll/sec

= ____ syll/sec

= ____ syll/sec

_____ syllables/

_____ syllables/

_____ syllables/

_____ seconds

_____ seconds

_____ seconds

= ____ syll/sec

= ____ syll/sec

= ____ syll/sec

_____ syllables/

_____ syllables/

_____ syllables/

_____ seconds

_____ seconds

_____ seconds

= ____ syll/sec

= ____ syll/sec

= ____ syll/sec

_____ syllables/

_____ syllables/

_____ syllables/

_____ seconds

_____ seconds

_____ seconds

= ____ syll/sec

= ____ syll/sec

= ____ syll/sec

/tʌ/

/kʌ/

/pʌtʌkʌ/

= ____ syll/sec

= ____ syll/sec

= ____ syll/sec

Table 2–10.  Diadochokinetic (DDK) Comparative Data in Syllables/Second for Ages 2–15 Years Ages in Years

/pʌ / Mean (range)

/tʌ / Mean (range)

/kʌ / Mean (range)

/pʌtʌkʌ / Mean (range)

2–3a

3.86 (3.46–4.74)

3.83 (3.38–4.56)

3.56 (3.36–3.75)

3.41 (2.82–4.23)

4–5

4.21 (3.62–4.92)

4.35 (3.54–4.82)

3.89 (3.00–4.76)

3.70 (2.86–4.47)

6–7

4.45 (3.93–5.56)

4.46 (3.42–5.88)

4.04 (3.33–4.74)

3.86 (2.91–4.74)

8–9

4.78 (4.54–5.88)

4.7 (4.30–5.88)

4.26 (4.12–4.49)

4.32 (3.85–5.19)

10–11

5.1 (4.63–5.56)

5.03 (4.66–5.56)

4.62 (4.50–5.00)

4.92 (4.22–5.46)

12–15

5.9 (4.76–6.06)

5.25 (4.46–6.06)

4.91 (4.39–5.40)

5.55 (4.35–6.66)

a

Although data are available for 2- to 3-year-old children, it is not always possible to elicit the productions in a reliable and valid manner.

Note.  Adapted from “Oral and Laryngeal Diadochokinesis Across the Life Span: A Scoping Review of Methods, Reference Data, and Clinical Applications,” by R. D. Kent, Y. Kim, and L. Chen, 2021, Journal of Speech, Language, and Hearing Research, 1–50 (https://doi.org/10.1044/2021_JSLHR-21-00396).

54   Here’s How to Treat Childhood Apraxia of Speech

In addition to comparing the child’s DDK rates to the norms, note observations on rhythmicity, articulatory accuracy, voicing errors, sequencing errors, addition of a segment, deletion of a segment, consistency of errors, and ability to complete task. You can also compare the effort observed in producing AMRs to the SMR task. By the end of the structural-functional examination, you will be able to provide a summary that provides evidence of indicators for apraxia, dysarthria, a combination of the two, or neither. Another helpful part of the exam is the nonverbal oral motor apraxia (NVOA) exam. Children who have difficulty with sensorimotor planning of sequences of movement for speech may also have difficulty sequencing oral movement for nonspeech tasks. However, a child does not have to have NVOA to be diagnosed with CAS, nor does a child necessarily have CAS if they have NVOA. Table 2–11 provides a brief examination of NVOA. To provide scores for comparison on this NVOA task, data were retrieved from a study where children with galactosemia were compared to a control group (Carlock et al., 2019). The data provided in Table 2–12 are from 261 children ages 6 to 12 years without a speech sound disorder, as judged by having a GFTA-3 standard score of 76 or higher. These scores indicate

Table 2–11.  Examination for Nonverbal Oral Apraxia (NVOA) Single Nonspeech Oral Movements Give verbal directions, then model if necessary. 0 = imitates immediately 1 = mild groping; or delayed but successful 2 = groping or sequential efforts (up to four tries), then success 3 = could not achieve imitation even though there is purposeful effort 4 = Child does not/cannot attempt to do the task Blow out a candle

Smile

Puff out your cheeks

Smack your lips together

Clear your throat

Bite your lower lip

Score Sum Single Nonspeech Oral Movements Score ____________ (0–24 possible) Nonspeech Movement Sequencing (NSMS) Give verbal directions, then model if necessary (same scoring as above). Smile, Blow, Smile

Smack your lips together, then clear your throat

Sip through a straw, then bite your lower lip

Score Sum NSMS Score ____________ (0–16 possible) Sum PRAXIS Score ____________ (0–40 possible)

Open your mouth wide, then lick the back of your top teeth

Smile, Blow, Smile

Smack your lips together, then clear your throat

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   55

Table 2–12.  Nonverbal Oral Apraxia Average Scores With Standard Deviations and Ranges of Children With Typical Speech Development (GFTA-3 Standard Score of Over 75) Boys

Girls

6- to 7-year-olds (boys n = 35; girls n = 30)

4.3 (3.6) Normal range 0–10

2.5 (1.96) Normal range 0–6

8- to 9-year-olds (boys n = 50; girls n = 36)

2.3 (2.5) Normal range 0–6

1.9 (2.5) Normal range 0–6

10- to 12-year-olds (boys n = 51; girls n = 59)

1 (1.3) Normal range 0–3

1 (1.3) Normal range 0–3

that even children without speech sound disorders may have some difficulty with these tasks, and performance varies according to age and gender. As with all portions of the assessment, there should be a summary statement regarding the child’s performance on the NVOA including if the child’s performance fell within the normal range or not. For children below age 6 years, just descriptive results can be provided. The information provided by a NVOA assessment can guide how instructions are given during therapy. For example, if a child has NVOA and is having difficulty obtaining the articulatory configuration for /k/, the therapist would be better off providing tactile and visual cues than verbal instructions.

Standardized Articulation and Phonology Assessment If a child is able to attempt word productions for the stimuli in a standardized articulation and phonology test, it can be helpful to do this prior to the sensorimotor speech exam, as it provides a way to sample all sounds in all word positions, enabling the examiner to obtain both an independent and relational sound inventory and a syllable shape inventory. Appendix 2–G provides diacritics typically used for disordered speech, exercises to practice identifying syllable shapes, and practice calculating percentage consonants correct (PCC) and percentage vowels correct (PVC). Table 2–13 provides a summary of commonly used standardized articulation and phonology tests and the ages they are normed for. When the child speaks a language other than English, it will be important to assess them in their first language as well (McLeod & Verdon, 2014). Table 2–25 provides a link to published tests and word lists in other languages (McLeod et al, 2012a).

Getting More Out of Your Standardized Articulation/Phonology Exam In addition to obtaining standardized articulation scores, the SLP can adapt how they administer the exam and use supplemental scoring methods to obtain information on inconsistency, vowel errors, segmentation errors, lexical stress matches, and response to dynamic cuing, as long as the standard score is based off the child’s first production (unless directed otherwise in the instruction manual). For example, eliciting multiple repetitions for a set of words (Diagnostic

Glaspey Dynamic Assessment of Phonology (Glaspey, 2021) (3;0–10;11)

Hodson Assessment of Phonological Patterns, Third Edition (HAPP3; Hodson, 2004) (3:0–8:0)

Arizona Articulation and Phonology Scale, Fourth Edition (Arizona-4; Fudala & Stegall, 2017) (18 months–21;11)

Diagnostic Evaluation of Articulation and Phonology (DEAP; Dodd et al., 2002) (3:0–8:11)

Goldman-Fristoe Test of Articulation 3 (GFTA-3; Goldman & Fristoe, 2015) (2;0– 21;11)

Test

X

Inconsistent Errors

*Includes 15-point cuing system that factors into the score

X

X

X

Stimulability

X

X

X

Vowel Errors

X

X

X

*When used with the Kahn-Lewis Phonological Analysis, Third Edition (KLPA-3; Kahn & Lewis, 2015)

Phonological Patterns

X

X

X

Sentence Level

Table 2–13.  Standardized Articulation and Phonology Examinations and the Components They Include

X

Oral-Motor Screening

56   Here’s How to Treat Childhood Apraxia of Speech

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   57

Evaluation of Articulation and Phonology [DEAP] uses 25) can be used to obtain a token inconsistency score. Iuzzini-Seigel (2021) uses stimuli from the GFTA-3 to calculate an inconsistency severity percentage (ISP) score, which you can learn more about from her online materials. Links are provided in Table 2–25. The SLP could use the child’s productions to compare the target syllable structure of the stimuli to the child’s production to obtain a percentage of articulatory accuracy for each syllable shape (e.g., CV, CVC, CCVC) at different syllable and word lengths. However, since most standardized articulation tests use primarily single syllable and bisyllabic words, additional stimuli will be needed to sample more complex syllable shapes and longer words, such as a picture description task. Patel and Connaghan (2014) published a free accessible picture description task of a Park Play scene with guidelines for analysis. Items in the scene include words with a variety of sounds, syllable shapes, and word lengths (e.g., boy, glasses, gingerbread, caterpillar). To access, go to the URL for the article provided in Table 2–25, and then go to the supplemental material link for the picture and analysis form.

Taxing the Sensorimotor Speech System The sensorimotor speech evaluation (typically referred to as a motor speech evaluation) should sufficiently tax the child’s sensorimotor planning system to precisely identify the levels at which breakdowns are occurring. Because the core impairment in CAS is the sensorimotor planning and/or programming of speech movement sequences, the evaluation for CAS should incorporate the production of movement sequences that vary in syllable shape complexity, number of syllables, phonetic complexity, and linguistic complexity. Children’s production of increasingly complex syllable/word structures, as measured by syllable shape complexity and number of syllables, should be completed to determine whether the complexity of utterances impacts the child’s production accuracy. The point at which the syllable structure of the words becomes too complex or the number of syllables in the word becomes too great for the child to produce accurately should be documented. Test items included in traditional articulation or phonology tests are not structured in a hierarchical format of syllable shape complexity. Many of the formal tests for CAS, which are included in Table 2–14, are structured in a format that moves from simple to more complex syllable shapes. For some children with CAS, the breakdown in accuracy may occur even at the level of the CV syllable. Other children may be able to maintain the integrity of the utterance until the utterance becomes longer (multiply/ multiplication; fridge/refrigerator) or the syllable structure is more complex (CVC, as in “top,” versus CCVCC, as in “stopped”). As the phonetic complexity of an utterance increases, the child also may demonstrate greater articulatory challenge. Words that contain consonant phonemes that require shifts in place, manner, and voicing — as well as vowels that require shifts in tongue backing and height, and lip shaping — likely will be more difficult for a child. Consider the following words: “cocoa,” “cookie,” and “cozy.” Each has two syllables and four phonemes, but the phonetic complexity builds with each target. In “cocoa,” the consonants and vowels are the same for each syllable; meanwhile in “cookie,” the consonants remain the same, but the vowel shifts from a high, back, lip-rounded vowel /ʊ/ to a high, front, lip-retracted vowel /i/. The same vowel shifting occurs in “cozy,” but there also is an additional change between the two consonants, with /k/ being a voiceless velar stop and /z/ being a voiced alveolar fricative. All of these articulatory changes can be taxing on the child’s sensorimotor planning system.

58   Here’s How to Treat Childhood Apraxia of Speech

The evaluation can uncover challenges when the linguistic complexity of utterances is increased as well. For children whose language is beyond the single-word level, it is essential to compare the child’s single-word productions to phrase- and sentence-level productions and conversation. Inconsistencies may be more noticeable during conversational speech than during single-word productions, especially for older children with CAS who are more conversational. Note any deterioration in phonetic or phonotactic accuracy or prosody as the utterance length increases, as these findings may be reflective of a breakdown at the level of sensorimotor planning and indicative of CAS. Connected speech-level analysis also is very important because it allows the clinician to observe the functional impact of the child’s speech disorder. Barrett and colleagues (2020) created a protocol for analyzing connected speech samples. The URL is provided in Table 2–25. The confirmation of the diagnosis of CAS is the part of the assessment that warrants the most attention. In lieu of a single gold standard assessment, perceptual assessments of core features through a variety of tasks that tax the sensorimotor system are what is typically used to diagnose CAS (Iuzzini-Seigel & Murray, 2017). Several studies have used Strand’s 10-point checklist (Shriberg et al., 2009), where the presence of CAS is confirmed if there is any combination of at least four of the 10 segmental and suprasegmental features listed, in addition to inconsistency (Murray et al., 2015). Iuzzini-Seigel (2021) proposes a 5-3-3 rule, where the child must demonstrate at least five of the core characteristics, three times each in three different contexts. Table 2–14 lists commonly used formal assessments and informal tasks that provide the examiner a variety of ways to measure and document the core characteristics and the age range for which they are appropriate.

Assessments and Tasks That Tax the Sensorimotor Speech System in Developmental Order There are currently three published pediatric sensorimotor speech exams available for purchase. They are all designed to tax the sensorimotor speech system by increasing phonetic and syllable shape complexity and length of the word. The Kaufman Speech Praxis Test for Children (KSPT; Kaufman, 1995) is norm-referenced for children age 2 to 5;11 years. It assesses imitation of oral movements, simple and complex phoneme production, simple to increasingly complex word shapes, and overall speech intelligibility. It also provides analysis and descriptive elements of other core characteristics observed during speech production, such as groping, inconsistency, vowel distortions, and atypical phonological patterns. Treatment recommendations are based on the level of complexity the child breaks down at and uses progressive approximation to help the child go from a motorically simpler version of a word to the correct production of the word following the order of how a typically developing younger child would say the word at different stages of development. For example, if the child struggles with CV-CV and says “ah-ah” for “bubble,” the child will work on the duplicated syllable, “buh-buh,” and then “bu-bo,” and then “bubble.” The Kaufman Speech to Language Protocol (K-SLP) provides materials using this method and is discussed further in Chapter 4. The Dynamic Evaluation of Motor Speech Skill (DEMSS; Strand & McCauley, 2019) is a criterion-referenced assessment to use with young children, ages 3 years and older with severe SSDs and reduced phoneme and syllable shape inventories. Stimuli include simple syllable shapes of increasing levels of complexity with early developing sounds. In addition, bisyllabic and trisyllabic words elicit both trochaic and iambic stress patterns. Words build in complexity in the following order: CV (e.g., go), VC (e.g., up), reduplicated syllables (e.g., papa), single sylla-

X X X

Vowel errors

Intrusive schwa

Consonant distortions/

x

x

x

x

X

x

x

x

X

X

x

VMPAC-R (3;0–12;0)

x

x

x

x

x

x

x

x

x

DDK task (4;0 to adult)

x

x

x

x

x

x

x

x

x

x

x

Multisyllabic word repetition (4;0 to adult)

x

x

x

x

x

x

x

x

x

x

x

Phrase repetition (when able)

x

x

x

x

x

x

x

x

x

x

x

Connected speech sample (all ages)

Notes.  DDK, diadochokinetic; DEMSS, Dynamic Evaluation of Motor Speech Skill; SSD, speech sound disorder; VMPAC-R, Verbal Motor Production Assessment for Children–Revised.

x

x

Equal or excess stress

x

x

Slow rate

Groping

x

Syllable segmentation

x

x

Difficulty with initial articulatory configurations or transitionary movement gestures

x

X

X

X

Kaufman (2;0–5;11)

Resonance or nasality disturbance

x

Increased difficulty with increased phonetic complexity, syllable shape and syllable length

distorted substitutions

X

Inconsistent errors

Characteristic

DEMSS (3;0 and older with severe SSDs)

Test or Task

Table 2–14.  Tasks for Identifying Core Features of CAS and Suggested Age Range

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   59

60   Here’s How to Treat Childhood Apraxia of Speech

bles with the same consonant (e.g., pop), with different consonants (e.g., home), bisyllabic words with one consonant and two vowels (e.g., baby), bisyllabic words with varied sounds, syllable shapes, and stress patterns (e.g., Open/today), multisyllabic words (e.g., banana/ peekaboo). The examiner scores vowel accuracy, articulatory accuracy after the first attempt, articulatory accuracy after cuing, and inconsistency after three repetitions of each word. Bisyllabic and trisyllabic words receive a score for prosodic accuracy. Scoring on this exam is multidimensional. For example vowels are scored as correct (2), uncertain (1), or distorted (0). To account for how children perform with additional cuing or if their errors fall more into a phonological error pattern, the articulatory accuracy score is judged as correct on first attempt (4), consistent developmental substitution error (3), correct after self-correction with no intervening model (2), correct after first cued trial (2), correct after additional cued trials (1), and not correct on final noncued elicitation after all cued attempts (0). Consistency and prosody scores are binary, meaning either correct (1) or incorrect (0). In addition to the scoring, the DEMSS provides a place for the examiner to tally the different types of prosodic errors they are hearing (e.g., segmented, equal stress, incorrect stress) and other characteristics consistent with CAS, such as inconsistent voicing errors, groping, intrusive schwa, slow rate, and awkward movement transitions. The examiner then calculates scores for vowels, articulatory accuracy, prosody (lexical stress accuracy), and consistency. Scores can fall in the range of “significant evidence for CAS,” “some evidence for CAS,” and “little or no evidence of CAS.” The other core characteristics observed are tallied but do not factor into the score. This provides a rich interpretation of the data, even if the child is unable to complete the assessment. The only characteristic not explicitly listed in the protocol is resonance. However, this could be included in the comments section. The DEMSS manual comes with a link to online resources that include fillable protocols and tutorials on how to score. The tutorials are very helpful, as it can take some practice to get reliable with the multidimensional scoring and scoring prosody and vowels accurately. SLPs often have a lot of training articulation errors when it comes to consonants. Many of us need additional practice with correctly judging vowels and prosody. Results from the DEMSS provide a natural segue into implementing the Dynamic Temporal Tactile Cuing (DTTC) approach. In DTTC, functional words and phrases are targeted that are within the zone of proximal development (ZPD) and can be achieved with maximal cuing. As the child’s motor sequencing of articulatory movement improves, cuing is faded. See Chapter 4 for more information on DTTC. The Verbal Motor Production Assessment for Children–Revised (VMPAC-R; Hayden & Namasivayam, 2021) has the same elements as the original VMPAC (Hayden & Square, 1999) but is now completely digital and is administered and scored on a computer. It is designed to assess the neuromotor integrity of the motor speech system for children ages 3 to 12 years with SSDs. The VMPAC-R tests motor complexity of speech and nonspeech movements in terms of coordinating planes of movement with increasing linguistic (e.g., phoneme, syllabic, word, and phrase level) and cognitive load (e. g., picture formulation/narration). Planes of movement including vertical movement of the jaw opening; horizontal movement of the lips in terms of rounding and retraction; and anterior-posterior movement of the tongue are aligned with the Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) Motor Speech Hierarchy (MSH), which is explained further in Chapter 4. This allows the clinician to systematically study the impact of higher cognitive load on the breakdown of sequencing ability in children. It also has a dynamic component, where the examiner can see which modalities (e.g., auditory, visual, tactile) help the child with their motor speech control. The five test components are as follows:

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   61

• global motor control, which includes head and trunk stability, respiratory and phonatory support, reflexes, and the vegetative functions of chewing and swallowing • focal oromotor control of mandibular, labio-facial, and lingual structures during nonspeech and speech movements • sequencing of nonspeech and speech movements • connected speech and language control • Speech characteristics, which comprise oromotor production in automatic verbal sequences and self-formulated speech to assess overall speech characteristics, such as voice quality, pitch, loudness, and prosody The new digital administration format provides video instructions embedded into the exam and training materials, which help standardize the administration of the assessment and scoring, and interpretation of results are online. The scores from each section auto populate onto the results page and are presented as a graphic display of the child’s percentage accuracy and percentile for each area. The results page also provides the examiner with the corresponding severity rating for each area. Results of this exam guide the therapist to start treatment where the child needs support (i.e., where their performance falls on the motor speech hierarchy using PROMPT). Targets for treatment are carefully constructed to systematically address physiological support and movement parameters for speech. You can preview the video tutorials and learn more about the VMPAC-R online. (See URL in Table 2–25.) If formal assessments are not available, the SLP can construct their own stimuli to see where the child breaks down and provide cuing to see what supports the child needs to improve articulatory accuracy. Tables 2–15 through 2–17 provide examples. Table 2–15.  Build Upon Words (One, Two, Three Syllables) Ann

anna

animal

bass

basket

basketball

me

meaty

medium

some

summer

summertime

won

wonder

wonderful

Table 2–16.  Build Upon Syllables (One-Syllable Words) soup

scoop/coops

scoops

cap

scam/camp

scamp

wish

swish/wished

swished

lamb

clam/lamp

clamp

well

dwell/welled

dwelled

rat

raft

draft

sad

sand

scanned

puck

punk

spunk

wet

sweat/wept

swept

gas

grass

grasp

62   Here’s How to Treat Childhood Apraxia of Speech

Table 2–17.  Phrases of Increasing Length I want more.

I want more milk.

I want more milk please.

Can we go?

Can we go home?

Can we go home now?

Wanna play?

Wanna play house?

Wanna play house with me?

Let me.

Let me try.

Let me try one.

School Age As the child becomes more able to sequence articulatory movement for single and bisyllabic words and basic sentences, the previously listed formal and informal sensorimotor speech assessments may no longer be adequate. Several studies have shown that children with CAS often struggle with multisyllabic words up through adolescence (e.g., Benway & Preston, 2020). “By 7;11 years, most children with typically developing speech and language will produce all consonants, vowels, syllable shapes, and stress patterns correctly” (Masso et al., 2018, p. 44). Carefully designed multisyllabic word repetition and/or picture naming tasks can tax the sensorimotor speech system at the next level and help differentiate children with CAS from other speech sound disorders (Benway & Preston, 2020; Murray et al., 2015). How the child performs on the multisyllabic word task can also guide the SLP in determining the next step of phonotactic complexity to address in therapy. Working on multisyllabic words for improved sensorimotor speech skills has the additional benefit of addressing tier II and tier III vocabulary and morphology, allowing the child to feel more confident when engaging with peers in and outside of the classroom. When choosing multisyllabic stimuli, the examiner will want to use or construct a word list that contains a variety of syllable shapes in words ranging from three to five syllables with different lexical stress patterns. Table 2–18 provides an abbreviated version of our Dynamic Multisyllabic Word Probe (DMWP) for the purpose of instruction. The full probe can be found in Appendix 2–E. This DMWP recording form was created based off of the characteristics often cited in the research, in addition to the authors’ combined 70 years of clinical experience. Core characteristics observed in school-age children with CAS have included syllable segregation, decreased PCC, decreased lexical stress matches, more voicing errors, lower percentage of structurally correct words (i.e., syllable shape), and more syllable deletions compared to peers with other SSDs (Benway & Preston, 2020; Murray et al., 2015). For this probe, use the child’s first production to score articulatory accuracy, coarticulation, and lexical stress accuracy. The recording form provides a place to transcribe incorrect words or simply mark the sound the child omitted, distorted, or substituted on the word written in International Phonetic Alphabet. This will allow for a quick calculation of percentage phonemes correct (PPC), PCC, and PVC analysis, if desired. Table 2–18 provides an example of how to adapt the form for these calculations. Otherwise, the examiner can mark the word with a + if correct and transcribe if incorrect. The form provided in Appendix E does not include PPC, PCC, and PVC, but it could easily be written in. It is important to note that the IPA transcriptions provided on the form are not representative of all dialects; thus, the examiner needs to be mindful of what is acceptable in the child’s dialect and score accordingly. Appendix 2–G provides instructions on how to calculate these scores. If only consonants are in error, it is not necessary to calculate PVC. In the following example, it shows how you could average these scores for words at each syllable length. This is helpful for seeing if accuracy decreases as syllable length increases.

Table 2–18.  Dynamic Multisyllabic Word Probe Transcribe or mark sounds that were incorrect, added, or omitted, if incorrect

Smooth coarticulation + good smooth coarticulation − poor coarticulation − syllable segmentation

Target Word

Lexical stress accuracy + correct − incorrect

If incorrect, is there improvement with backward chaining or other cuing methods? Y/N If so, note the method that was helpful.

Three-Syllable Words vacation

___ /7 P

/ve.ˈkeɪ.ʃən/

___ /4 C ___ /3 V

subtraction

___ /10 P

/səb.ˈtræk.ʃən/

___ /7 C ___ /3 V

principal

___ /9 P

/ˈprɪn.sə.pəl/

___ /6 C ___ /3 V

Total for threesyllable words

___ /26 P ___ /17 C ___ /9 V Four-Syllable Words

avocado

___ /7 P

/ɑ.və.ˈkɑ.doʊ/

___ /3 C ___ /4 V

television

___ /9 P

/ˈte.lə.vɪ.ʒən/

___ /5 C ___ /4 V

experiment

___ /11 P

/ɛk.ˈspɛ.rɪ.mənt/

___ /7 C ___ /4 V

Total for four-syllable words

___ /25 P ___ /14 C ___ /12 V continues

63

64   Here’s How to Treat Childhood Apraxia of Speech

Table 2–18.  continued Transcribe or mark sounds that were incorrect, added, or omitted, if incorrect

Smooth coarticulation + good smooth coarticulation − poor coarticulation − syllable segmentation

Target Word

Lexical stress accuracy + correct − incorrect

If incorrect, is there improvement with backward chaining or other cuing methods? Y/N If so, note the method that was helpful.

Five-Syllable Words congratulations

___ /14 p

/kənˌɡræ.,t͡ʃəˈleɪ.ʃənz/

___ /9 c ___ /5 v

enthusiasm

___ /11 p

/ɛn.ˈθu.zɪ.jæ.zəm/

___ /6 c ___ /5 v

evaporation

___ /10 p

/ɪ.væ.pə.ˈreɪ.ʃən n/

___ /5 c ___ /5 v

Total for five-syllable words

___ /35 p ___ /20 c ___ /15 v

Note.  Adapted from “Dynamic Multisyllabic Word Probe,” by A. Skinder-Meredith and M. Fish, 2022 [Unpublished].

The third column of the record form provides a place to mark if the word was said with smooth coarticulation or if it sounded segmented. The presence of linguistically inappropriate silent pauses is a strong indicator of CAS (Shriberg et al., 2017). However, the time it takes to do the acoustic analysis necessary to determine silent pause markers, as defined by Shriberg and colleagues (2017), is not clinically feasible. Noting if a word was produced with poor coarticulation and/or syllable segmentation is a perceptual task that is relatively quick and shown to be indicative of CAS as well. In the fourth column, the examiner notes if the lexical stress pattern was correct or not. If the child uses a different stress pattern and/or deletes any of the syllables, it is marked as incorrect. In the last column, the examiner notes if backward chairing or any other cues helped improve accuracy. Backward chaining, also called backward build-ups, facilitates improved articulatory accuracy while maintaining the correct stress pattern versus saying one syllable at a time, which leads to segmented syllables and an equal stress pattern with longer duration

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   65

on the last syllable. To demonstrate, let’s use the word, “majestic.” You would first have the child repeat the last syllable, “stic,” and then the last two syllables “gestic,” and then put the word all together, “magestic.” Now try the traditional one syllable at a time method, “ma….je….stic.” Do you hear the difference? Knowing that children with CAS struggle with prosody and coarticulation, the backward chaining method is preferable. For more on this technique, see Chapters 3 and 5. If the child is struggling on one syllable in particular, you can work on that syllable in isolation with additional cuing, such as simultaneous production and tactile cuing, and then put it back into the whole word. If the child said the word correctly the first time, you could write NA for not applicable. This will be helpful when planning treatment. You do not need to elicit all words on the DMWP, just enough to get a sense of where the child breaks down. There are several multisyllabic word lists available online, such as the 10 Clinically Useful Words available on Caroline Bowen’s website and the Single Word Test of Polysyllables (Gozzard et al., 2008) in addition to word lists that are provided in the research (Benway & Preston, 2020; Masso et al., 2018). URLs for the 10 Clinically Useful Words and the Single Word Test of Polysyllables (Gozzard et al., 2008) are presented in Table 2–25.

Considerations for Taxing the Sensorimotor Speech System in Children Who Speak Languages Other Than English When working with children who speak a language other than English, the SLP can determine appropriate stimuli by using the same principles previously discussed. In other words, the SLP can find words and phrases from the child’s language that build in phonetic complexity, syllable shape, word length, and phrase length. An example of stimuli for Spanish is in Box 2–3. In addition to building complexity, the SLP can use the dynamic cuing discussed on the DEMSS and note the level the child makes errors and where they improve with additional cuing. Also note observations of inconsistency, stress errors, and segmentation of sounds and syllables. Determining the appropriate stimuli will require some homework on the part of the SLP. Fortunately, access to information on the phonology of different languages, order of sound acquisition, and first words spoken in most languages can be found by doing a literature search (McLeod & Crowe, 2018). The Charles Sturt University website on multilingual children’s speech (http://www.csu.edu.au/research/multilingual-speech/home) and ASHA’s Practice Management/Multicultural page (https://www.asha.org/practice/multicultural/ phono/) provide links to multiple resources for finding this information.

Inconsistency Measurements Inconsistency is the most commonly listed core characteristic of CAS. However, there are many ways to measure inconsistency, and sensitivity of the type of measure used can depend on the age of the child and the complexity of the task (Iuzzini-Seigel, 2021; Iuzzini-Seigel et al., 2017). Token-to-token inconsistency measures are used to calculate the inconsistency of words or phrases over multiple repetitions. For example, on the DEAP, a child repeats 25 words three times each, and if 12 of the words are produced differently in at least two of the three

66   Here’s How to Treat Childhood Apraxia of Speech

Box 2–3. Example of Building Stimuli in Spanish Isolated vowels:  /i/, /e/, /ɑ/, /o/, /u/ CV syllables:  mí (my), no (no), yo (I), tú (you), sí (yes) VC syllables:  en (on), el (the) C1V1C1V1:  mamá, papá CVC syllables:  pan (bread), con (with), más (more), mal (bad), luz (light) VCV:  ojo (eye), oso (bear), hola (hello), año (year) C1V1C1V2:  dedo (finger) C1V1C2V1:  vaca (cow), cama (bed), taza (cup) C1V1C2V2:  pato (duck), gato (cat), queso (cheese) Words with clusters:  flan (custard), flauta (flute), plato (plate), gris (gray), blanco (white) Multisyllabic words:  tenedor (knife), juguete (toy), cuchara (spoon), comida (food), cumpleaños (birthdays) Words of increasing length:  es (is), está (is); pa (pa), pato (duck), zapato (shoe); gato (cat), gatito (little cat/kitten) Phrases of increasing length:  Quiero (I want), Quiero más (I want more), Quiero más leche (I want more milk), Quiero más leche por favor (I want more milk please) Functional phrases:  Hola mamá/papá (hi mom/dad), Me gusta (I like), No me gusta (I don’t like), ayúdame (help me), Lo hago (I do it), ¿Quieres jugar? (Do you want to play?), No sé (I don’t know), Yo también (Me too) Elicit automatic speech tasks as well, such as counting to 10 (“Cuenta hasta diez”) and saying the alphabet (“Dime el alfabeto”).

repetitions, they would have a token-to-token inconsistency score of 48%. If the task was to repeat the same phrase five times and the child said it differently in two of the productions, they would receive an inconsistency score of 40%. Phonemic-level inconsistency (i.e., segmental-level inconsistency, speech error variability, or type-token ratio [TTR]) measures inconsistency of a phoneme across multiple productions of the phoneme in the same words and phrases or different words and phrases. This allows for a more sensitive measure and has been found to differentiate typically developing children from children with CAS at younger ages (Iuzzini-Seigel & Murray, 2017). An inconsistency severity percentage (ISP) by dividing the total number of different error types, minus one for each phoneme, by the total number of target opportunities (Iuzzini & Forrest, 2010). Table 2–19 provides a comparison of a child with CAS and a child with phonological impairment when scoring inconsistency using ISP. For the purpose of demonstration, the example is only looking at the phoneme /s/. However, this can be done on more than one sound at a time, as is illustrated in Iuzzini-Seigel’s tutorial on measures of inconsistency.

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   67

When distinguishing children with CAS from children with speech delay, Iuzzini-Seigel and colleagues (2017) found that token-to-token inconsistency of monosyllabic words and five repetitions of the phrase “Buy Bobby a puppy” were the most sensitive measures for differentiating between the two groups. For the phrase repetition, a sentence inconsistency percentage score is calculated by dividing the number of different ways the sentence was produced by the total number of trials and multiplying by 100. Table 2–20 provides an example of a child with CAS and a child with phonological impairment for scoring inconsistency using the sentence inconsistency percentage. Examples used in Tables 2–19 and 2–20 are based on theoretical cases consistent with the characteristics of the disorder to illustrate how the child with CAS is more apt to have higher inconsistency scores than children with phonological delay based on variability of consonant and vowel production.

Table 2–19.  Productions of Five Words Targeting /s/ Produced by a Child With CAS and a Child With Phonological Delay With Inconsistency Severity Percentage Calculation Target Production

Child With CAS

Child With Phonological Delay

messy

/mɛdɪ/

/mɛtɪ/

scissors

/dɪdɪ/

/tɪdɚz/

mass

/mæk/

/mæt/

house

/haʊʔ/

/haʊt/

swimming

/hwimɪŋ/

/twɪmɪŋ/

Inconsistency severity percentage

Four error types –1/ Five opportunities × 100 = 60%

One error type –1/ Five opportunities × 100 = 0%

Table 2–20.  Five Repetitions of “Buy Bobby a Puppy” Produced by a Child With CAS and a Child With Phonological Delay Repetition

Child With CAS

Child With Phonological Delay

First repetition

/ba.bɑpi.ʌ.pʌʔi/

/baɪ.bɑbi.ʌ.bʌbi/

Second repetition

/ba.bɑbi.ʌ.bʌʔi/

/baɪ.bɑbi.ʌ.bʌbi/

Third repetition

/baɪ.bɑbi.ʌ.bʌbi/

/baɪ.bɑbi.ʌ.bʌbi/

Fourth repetition

/baɪ.bɑbi.ʌ.bʌbi/

/baɪ.bɑbi.ʌ.bʌbi/

Fifth repetition

/baɪ.bɑʔi.ʌ.ʌʔi/

/baɪ.bɑbi.ʌ.bʌbi/

Sentence inconsistency percentage

Four different productions/ Five trials × 100 = 80%

Zero different productions/ Five trials × 100 = 0%

68   Here’s How to Treat Childhood Apraxia of Speech

Prosody Prosody refers to the suprasegmental aspects of speech and includes variation of pitch, loudness, duration, and articulatory effort. Assessing prosody can be done a number of ways. As already discussed, the DEMSS and multisyllabic word tasks provide a way of measuring lexical stress accuracy. In these tasks, we are listening for the stress to go on the correct syllable. A frequent observation of children with CAS is the characteristic of equal and excessive stress pattern. This means that the child does not unstress the unstressed syllable(s). For example, in the word “ba.na.na,” only the second syllable should be stressed. The child with CAS may stress every syllable, so it is “ba.na.na,” or delete the weak syllable(s) and only produce the stressed syllable, “na.” We also vary our prosody in sentences by changing our intonation patterns for statements versus questions or changing which syllable receives the stress for emphasis. Just as we used multisyllabic words to see where the child correctly matched the lexical stress pattern, we can use sentences to see if they can match the sentential stress and intonation pattern. Appendix 2–F includes a list of 10 three- to four-word sentences with a variety of intonation contours to denote a question, an exclamation, and a statement. The sentences are scored for ability to match the intonation contour, stress the correct syllable, and include all of the syllables. Phrases are intentionally short and syllable shapes are simple as to not tax the child’s memory or articulatory sequencing. It is also helpful to judge prosody in connected speech. Additional probes for assessing various features of prosody are discussed in Chapter 5, Table 5–7.

Speech Intelligibility and Comprehensibility Now let us come back to what is essential as we think about the International Classification of Functioning, Disability and Health–Children and Youth (ICF-CY) framework. At the end of the day, we want the child to be able to participate fully in all of their environments (e.g., home, school, extracurricular activities, etc.) with a variety of communication partners (e.g., family, friends, community members, etc.). To do this, one needs to be understood. Hence, speech intelligibility, “the degree to which the acoustic signal is understood by a listener” (Yorkston, Strand, & Kennedy, 1996, p. 55), is an important measure that corresponds with the “activity” and “participation” portions of the ICF-CY. The lower the child’s intelligibility, the more limited and restricted they are. Intelligibility can be measured by calculating the percentage of words understood (i.e., a word identification task) or using a scaled rating system (e.g., a Likert scale ranging from unintelligible to intelligible). Each of these methods has their pros and cons. Where word identification approaches provide more specific measures for tracking progress, they are time consuming and not always feasible (Allison, 2020). Scaled rating approaches provide the option of giving an overall measure of severity and are more ecologically valid, especially when used with a variety of listeners (McLeod et al., 2012b). Although there are many variables to consider when determining intelligibility (e.g., length of sentence, knowledge of context, phonetic complexity and length of the words, speech elicitation method, etc.), strictly speaking, the measure is dependent on the acoustic signal alone. See Table 2–21 for a summary of intelligibility methods.

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   69

Table 2–21.  Tasks and Procedures for Measuring Speech Intelligibility Task

Procedure

Single-word identification, open set

The child is recorded saying a list of target words. The targets could be elicited using picture naming or imitation. An unfamiliar listener transcribes the words they heard. The percentage of words correctly identified is calculated.

Single-word identification, closed set

Elicitation is the same as above, but rather than transcribing the word, the listener is given a choice of phonetically similar words and circles the one they heard. The percentage of words correctly identified is calculated.

Word identification at the sentence level

The child produces a set of target utterances following a model, and the listener transcribes the sentences they heard. The percentage of words correctly transcribed is calculated. To track progress over time, the sentences should be similar in length and complexity, as illustrated in Table 2–22.

Intelligibility of words from a spontaneous speech sample

The listener transcribes the recording of what the child said and places an X for each word they did not understand. To compare scores over time, the SLP could elicit the connected speech from a picture description task, a narrative of a familiar story, or while playing with the same set of toys that were used in their prior speech sample.

Percent Consonants Correct (PCC)

PCC can be derived from transcriptions of articulation test productions or spontaneous speech. PCC has been shown to have moderate to strong positive correlations with intelligibility.

Comprehensibility is a broader term and goes beyond just the auditory signal. Comprehensibility refers to how well the listener understands the speaker when using all of the available cues, such as gestures, pictures, sign language, augmentative and alternative communication, body language, and knowing the context. For this reason, comprehensibility will be higher than intelligibility. Comprehensibility measures are more ecologically valid but do not directly reflect the accuracy of the speech signal (Allison, 2020). Goals can be written for improving both intelligibility and comprehensibility. There are a number of options for calculating a percentage of speech intelligibility score and variables to consider when choosing the option that is the most appropriate for the child you are assessing. When using an intelligibility measure for the purpose of tracking progress, the procedure used needs to be consistent due to the many factors that can impact the score, such as predictability of the word or sentence, length of the stimuli (e.g., word vs. sentence), phonetic complexity of the words, and familiarity of the listener. This is especially important to consider when a child goes from one therapist to another. The new therapist will need to know how the previous therapist determined the intelligibility score for reliable tracking of progress. Intelligibility assessments for children have been primarily used for research purposes, and the ones that have been published for clinical use are no longer in print (Allison, 2020).

70   Here’s How to Treat Childhood Apraxia of Speech

Hence, the SLP is somewhat limited for options. The SLP can either make their own stimuli or use word and sentence lists published in the research (Ertmer, 2010). The URL addresses for a few of these measures are provided in Table 2–25. When using an imitation task for words and phrases, the recording will need to be edited or paused each time the model says the utterance, so the listener is naïve to the target. Ideally, the listener should not be familiar with the speaker and only be allowed to listen to the child’s productions twice (Allison, 2020). If the listener is familiar with the child’s speech, this should be noted when providing the intelligibility score, since an increase in familiarity with the speaker can increase the intelligibility score. Morris and colleagues (1995) created the Preschool Speech Intelligibility Measure (PSIM), which was developed in a manner similar to the Sentence Intelligibility Test (SIT) (Yorkston, Beukelman, & Hakel, 1996) for adults. The PSIM provides 50 sets of 12 phonetically similar words and is an example of a single-word identification with a closed set. For example, in list one, the words are as follows: warm, store, swarm, for, horn, corn, door, torn, born, floor, storm, form. The child repeats the words the clinician has preselected from each list. The SLP records the list set number and asks the child to repeat a word from the set and then records the child’s production only. There is approximately a 7-second pause between items, and then the SLP states the next item number, and the child repeats a word from that set. This continues until the child has been recorded saying one word from each of the 50 sets. The unfamiliar listener is then provided the recording and circles the word they heard using a multiple-choice format, which includes the 12 words for each set. The Beginner’s Intelligibility Test (BIT; Osberger et al., 1994) and the Monsen-Indiana University Sentences (M-ISU; Monsen, 1981) are examples of tasks used for word identification at the sentence level. The BIT consists of grammatically simple sentences that a young child who cannot read could easily repeat. In addition, the sentences are easy to demonstrate with objects and toys. For example, “The baby falls” would be modeled while having a baby doll fall. The M-ISU was developed for children in second grade or higher who can read, and the phrases range in phonetic complexity and length. Although both of these sentence intelligibility probes were developed for young children with hearing loss, they can be used with other pediatric populations as well. The URL for the article that contains the BIT and M-ISU stimuli is in Table 2–25. The sentence lists in Table 2–22 were created to be consistent with the principles used for the M–ISU. The sentences in these lists are two to six words in length and include the following features: multiple phonetic contexts, with and without consonant clusters, including final bound morphemes, early and later developing phonemes, words of one to three syllables in length, familiar vocabulary, and declarative and interrogative forms. The child is recorded while either repeating or reading these utterances and the naïve listener transcribes the sentences exactly as they heard them. The percentage of correctly transcribed words is then calculated for the intelligibility score. For example, if the listener heard “Mom walk baby” for “Mom walks the baby” the score would be 50% of words intelligible for that item. Note that each list of phrases is similar in terms of length and complexity. This allows the examiner to use a different list of phrases each time the child is recorded for the purpose of tracking improvement in speech intelligibility at the sentence level. Measures of PCC and percentage phonemes correct (PPC) have been found to correlate with intelligibility scores (Skoog & Maas, 2020). Some researchers and clinicians use the percentage of consonants correct–revised (PCC-R) score in single words and connected speech (Shriberg

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   71

Table 2–22.  List of Phrases and Sentences to Produce for Word Intelligibility at the Sentence Level Phrase and Sentence-Level Intelligibility Stimuli List 1

List 2

List 3

1. My toys

1. Go home.

1. Help me.

2. I see you.

2. I know Sue.

2. We saw two.

3. Where is daddy?

3. Why not, mommy?

3. Where is puppy?

4. Stop the car.

4. Stay right here.

4. She stayed home.

5. Mom walks the baby.

5. Dad takes the bus.

5. Bob bakes the cake.

6. It rained all day yesterday.

6. My friend touched the computer.

6. We laughed at the magician.

7. She won’t be at home tomorrow.

7. They don’t like to exercise much.

8. She’s dressing in fancy clothes.

8. Her plant needs more watering.

9. I started planting seeds today.

9. Don’t stand on the flowers.

10. Can your grandmother make sandwiches?

10. Did the principal want lemonade?

7. We can’t go to the library. 8. I’m putting the trucks away. 9. My special blanket is dirty. 10. Is Saturday your grandfather’s birthday?

et al., 1997). The PCC-R score can be useful for describing severity and can serve as a baseline for later comparisons. The following equation is used to calculate PCC-R: PCC-R = Number of correct consonants (excluding distortions) ÷ Total number of consonants × 100 Shriberg and Kwiatkowski (1982) used the following rating system for PCC scores: • Mild: 85%–100% • Mild-moderate: 65%–85% • Moderate-severe: 50%–65% • Severe:  below 50 Obtaining a percentage of intelligibility from orthographic transcription, even when provided a closed set to choose from, can be a time-consuming task. With the advent of speech recognition software, more products are being developed that measure speech intelligibility. For example, Rose Medical Speech Therapy Software & Instrumentation, out of the United Kingdom sells Pronunciation Coach 3D software for home use and for the commercial user. As part of the package, the speaker can record their speech and compare it with the pronunciation model to obtain an intelligibility score. For more information, go to the URL provided in Table 2–25. This software was developed with the intended use of improving speech intelligibility of English-language learners and people with speech sound disorders. Although the developers have not determined validity and reliability measures with people with disordered

72   Here’s How to Treat Childhood Apraxia of Speech

speech and are not SLPs, they are open to feedback and are continually working on making their products more clinically useful. Scaling scores for intelligibility are often used for rating spontaneous speech samples and can be used with a variety of listeners. McLeod and colleagues (2012) developed the Intelligibility in Context Scale (ICS) to measure functional intelligibility of young children with speech sound disorders and CAS. Given that the rater is provided contextual cues, the ICS and other rater scales are more of a comprehensibility measure than a strict intelligibility measure. The ICS is filled out by the caregiver and consists of seven questions relating to how well the child is understood by different communication partners (e.g., parents, friends, family, acquaintances, teachers, and strangers). It has a 5-point rating scale, ranging from 1, the child is never understood, to 5, they are always understood. This ICS can be found online and is available to download in 60 languages by going to the URL listed in Table 2–25. See Figure 2–4 for the English version.

Figure 2–4.  Intelligibility in Context Scale. (Intelligibility in Context Scale by S. McLeod, L. J. Harrison, and J. McCormack, 2012, Charles Sturt University, http://www.csu.edu.au/research/multilingual-speech/ics. Used with permission of Sharyn McLeod.)

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   73

Although there are many scales available, the ICS is the only one that has been translated into 60 languages and has tested validity and reliability across 14 languages (McLeod, 2020). In a study by Soriano and colleagues (2021), ICS composite scores were compared to transcription intelligibility scores of 48 children with cerebral palsy (CP). The transcription intelligibility score was based off of the percentage of words transcribed correctly from 60 multiword utterances. Given the efficiency of filling out the ICS, it was encouraging to see that the ICS composite scores were moderately strong predictors of transcription intelligibility scores (Soriano et al., 2021). In this study, a composite score below 4 indicated the child had a speech motor impairment. This is a helpful cutoff score to be aware of when interpreting results of the ICS.

Comprehensibility Some children with poor speech intelligibility have figured out ways to be understood by using a variety of strategies. When working to improve a child’s comprehensibility, we can work on both increasing the child’s articulatory and prosodic accuracy, while also giving them ways to compensate for their difficulties with motor planning and programming. Table 2–23 provides a comprehensibility strategies checklist for the parent to fill out. If working with a child in the school, this may also be appropriate for the teacher to fill out. The list is in developmental order of strategies we may expect to see a child use.

Table 2–23.  Comprehensibility Strategies Checklist Check the strategies your child uses to be understood Pantomimes and/or uses gestures Points to the object of a picture of what they are referring to Uses prosody and emphatic stress with word approximations (e.g., “I WA ta o O!” for “I want to go home.”) Uses sign language and/or other forms of augmentative communication Decreases rate of speech Repeats the part of the message not understood Types or writes what is not understood Uses synonyms for what is not understood Provides context for what is not understood Pulls up an image or story on the Internet to show what they are referring to Other

Yes

No

Unsure

74   Here’s How to Treat Childhood Apraxia of Speech

Differential Diagnosis and Relative Contribution When Morley and colleagues (1954) first noted characteristics of apraxia in children, SLPs were only aware of pediatric dysarthria, and it took a long time for many to accept that CAS even existed (ASHA, 2007). However, as noted earlier, current studies indicate that SLPs are not as comfortable with diagnosing childhood dysarthria as they are with diagnosing CAS and may miss potential dysarthric components impacting the child’s speech production (Murray et al, 2015; Iuzzini-Seigel et al., in press). In addition, it can be easy to overlook a phonological disorder when the focus is on CAS. We are now more aware that children with severe speech sound disorders may have CAS, dysarthria, a phonological disorder, or a combination of any of the three. Table 2–24 provides a comparison of the characteristics observed in CAS, dysarthria, and phonological disorder. To aid in differential diagnosis and determine the relative contribution of each underlying deficit to the child’s speech disorder, the examiner can highlight the saliant characteristics listed in Table 2–24 to get a more comprehensive picture as to what may be going on for a particular child. This can then help guide the clinician’s treatment plan to address the issues that are having the biggest impact on speech intelligibility. The Profile of Childhood Apraxia of Speech and Dysarthria (ProCAD) is a new checklist that will be helpful in discerning CAS from childhood dysarthria (Iuzzini-Seigel et al., 2022). The ProCAD uses a binary scoring system (present or not present) for twenty speech features organized by subsystem, which are characteristic of dysarthria, CAS, or both. For example, short breath groups, which falls under respiration and phonation would be indicative of dysarthria; slow rate, which falls under prosody, could suggest both CAS or dysarthria; and intrusive schwa, under articulation, would be symptomatic of CAS. The examiner completes the feature checklist across three different speech tasks (e.g., articulation test, multisyllabic words, and connected speech). A diagnostic flowchart is then used to determine if dysarthria or CAS are present, should be further tested, or ruled out. Table 2–24.  Differentiating Characteristics of CAS, Dysarthria, and Severe Phonological Disorder Severe Phonological Disorder

Speech Features

CAS

Dysarthria

Weakness

No weakness, incoordination, or paralysis of speech musculature

Decreased strength and/or coordination of speech musculature that leads to deficits in respiratory support and/or coordination; voice impairment and imprecise speech production, slurring and distortions

No weakness, incoordination, or paralysis of speech musculature

Difficulty with involuntary motor control for chewing, swallowing, etc., due to muscle weakness and incoordination

No difficulty with involuntary motor control for chewing and swallowing

*However, children with CAS may present with low tone.

Involuntary motor control

No difficulty with involuntary motor control for chewing, swallowing, etc.

Table 2–24.  continued

Speech Features

CAS

Dysarthria

Severe Phonological Disorder

Inconsistent speech errors

Inconsistencies in articulation performance — the same word may be produced several different ways

Articulation may be noticeably “different” due to imprecision, but errors generally consistent

Consistent errors that can usually be grouped into categories (fronting, stopping, etc.)

Types of sound errors

Sound errors may include vowel distortions, omission of initial consonants, and additions. Tendency to centralize vowels to a “schwa” or produce syllable final schwa

Errors are generally weak and imprecise distortions

Errors may include substitutions, omissions, distortions, etc. Omissions in final position more likely than initial position. Vowel distortions not as common.

Increased errors with increased word/phrase length

Number of errors increases as length of word/phrase increases

May be less precise in connected speech than in single words

Errors are generally consistent as length of words/phrases increases

Rate, rhythm, stress

Rate, rhythm, and stress of speech are disrupted, some groping for placement may be noted

Rate, rhythm, and stress are disrupted in ways specifically related to the type of dysarthria (spastic, flaccid, ataxic, etc.)

Typically, no disruption of rate, rhythm, or stress

Pitch and loudness

Generally good phonatory quality and normal volume, and physiological control of pitch and loudness is typically normal.

May have difficulty controlling pitch and loudness depending on the type of dysarthria

Good control of pitch and loudness, not limited in inflectional range for speaking

Speech prosody

Prosodic deficits often noted: equal stress, segmentation, lexical stress errors

Prosodic deficits common, varying with type of dysarthria

Typically, no prosodic deficits

Voice quality

Age-appropriate voice quality

Voice quality may be harsh, hypernasal, etc., depending on type of dysarthria

Age-appropriate voice quality

Nasal resonance

May be hypernasal due to mistiming but also look for structural deficits (e.g., submucosal cleft)

Often see hypernasality

Not typically associated with phonological impairment

Note.  From Dave Hammer, MA, CCC-SLP, Ruth Stoeckel PhD, CCC-SLP, and Edythe Strand PhD, CCC-SLP, 2018. Updated 2021 by Margaret Fish, MS, CCC-SLP. Updated 2022 for Apraxia Kids website. Used with permission from Apraxia–Kids.

75

76   Here’s How to Treat Childhood Apraxia of Speech

Other Areas of Assessment Up to now, this chapter has focused on the components of the assessment battery that allow the examiner to determine if the underlying deficit of the child’s speech sound disorder is structural, phonological, motor execution, sensorimotor planning and programming, or a combination of factors. As mentioned earlier, it will also be important to assess language, phonological awareness, and literacy skills, in addition to screening for fine motor and gross motor skills, and sensory processing, and monitoring social-emotional well-being.

Language Testing • Receptive language.  Describe the child’s receptive language capacities in the following areas. When receptive language challenges co-occur with CAS, the child may exhibit difficulty understanding the instructions for the tasks presented. Adaptations may need to be made in the length and format of verbal instruction provided to the child during treatment. • Vocabulary and concept knowledge • Syntax and morphology • Question comprehension • Following directions of increased length and complexity • Language processing • Working memory

• Expressive language.  A thorough examination of expressive language (vocabulary, syntax, morphology, narrative language) will help guide the treatment goals as well as the target vocabulary and utterances. More detailed information related to target selection and elicitation of phrases and sentences can be found in Chapters 6 and 8 of this book. • Syntax and morphology challenges may be a result of phonetic inventory limitations (e.g., child produces “cup” for cups because CVCC is not in the child’s inventory). Even those errors not impacted by a child’s phonetic inventory are a common finding in children with CAS (e.g., child produces “go” for goes even though the child’s word shape inventory does include CVC). Other linguistic challenges may include reduced length and complexity of utterances, omission of function words, word sequencing errors, and incorrect pronoun usage. • Word retrieval concerns, if any, should be noted. Word retrieval challenges may be unrelated to the child’s apraxia or may reflect difficulty with planning the phoneme sequences of the target utterances. • Narrative language in children who are conversational should be assessed and addressed if the child exhibits difficulties in the ability to share stories in a sequential, cohesive, and age-appropriate manner.

• Social-pragmatic language.  Social language differences may result from a child’s limited opportunities for early verbal interactions but also may be indicative of a co-occurring social language disorder. The following should be noted:

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   77

• Conversational reciprocity with peers and adults.  For children who are conversational, note whether there are any difficulties in reciprocal conversational skills, and whether the child demonstrates a better ability to be reciprocal with adults than with peers. • Language functions.  Indicate whether the child demonstrates use of a limited variety of language functions, which may be an indication of concomitant social language challenges. Some examples of language functions include greeting, requesting objects, actions, or assistance, rejecting, protesting, sharing information, narrating events, expressing humor, getting attention, and commenting. • Level of engagement and interaction (verbal and nonverbal).  Indicate whether the child prefers to play alone or with others and whether the child engages in cooperative play with peers. If the child’s play tends to be parallel or solitary beyond the age of 4 years, the age at which cooperative play would be expected, this should be noted and may need to be addressed in treatment.

Phonological Awareness and Literacy As noted in Chapter 1, children with CAS often have difficulty with phonological awareness and literacy skills. There are many good screening tools and assessments for children age 4 years and up. There are also many online materials that can be used to assess phonological and phonemic awareness in the areas of alphabet knowledge, segmenting sounds and syllables of a word, blending sounds, rhyme awareness, and manipulation of phonemes (e.g., adding, substituting, and deleting sounds) to make new words. One such online screener is the Phonological Awareness Screening Test (PAST; Kilpatrick, 2019) for Pre-K through adult. The link is provided in Table 2–25. Following is a list of frequently used assessments for phonological awareness and literacy: Standardized Assessments Phonological Awareness Tests and Literacy • Comprehensive Test of Phonological Processing, Second Edition (CTOPP-2) (Wagner et al., 2013) (ages 4;0–24;11) • Lindamood Auditory Conceptualization Test, Third Edition (LAC-3) (Lindamood & Lindamood, 2004) (ages 5;0–18;11) • Test of Phonological Awareness, Second Edition: PLUS (TOPA-2+) (Torgensen & Bryant, 2004) (5 through 8 years) • Test of Integrated Language & Literacy Skills (TILLS) (Nelson et al., 2016) (ages 6 through 18 years)

Speech Perception Zuk et al. (2018) found that children with CAS and language delay did significantly worse than children with CAS without language delay in their ability to distinguish “da” from “ga.” Given the comorbidity of CAS and language disorders and results from previous studies showing that children with CAS often have difficulty with speech perception (Groenen et al., 1996; Ingram et al., 2019; Maassen et al., 2003; Nijland, 2009), we suggest assessing discrimination of the sounds in error. For example, if they make prevocalic voicing errors, probe their

78   Here’s How to Treat Childhood Apraxia of Speech

ability to discriminate voiced and voiceless cognates. The authors’ experience of working with children with CAS has shown them that voicing errors, especially prevocalic voicing, as in “big” for “pig” and vowel errors could be due to poor discrimination, in addition to sensorimotor planning and programming. Examples of assessments for speech perception are as follows: • Speech Assessment and Interacting Learning (SAILS) (Rvachew & Brosseau-Lapré, 2021) has been updated from the original computer-based tool and is now available as an app for iPads. It is designed for younger children and provides graphics and auditory stimuli with a variety of voices (e.g., adult and children). The child hears the word with the target sound said correctly and incorrectly and makes a binary choice as to if the production is correct or incorrect. • The Locke Speech Perception-Speech Production Task (Locke, 1980) examines the child’s ability to perceive the errors they are making. For example, if the child says the initial sound in “ship” incorrectly, the examiner will then see if the child can perceive the correct production of this word by showing an image of a ship and then asking the child to judge if the examiner said the right word when providing incorrect and correct productions of the word (e.g., Is it a “fip”? Is it a “sip”?, Is it a “ship,” etc.)? Three or more errors out of six opportunities indicates the child is having difficulty correctly perceiving the target phoneme. For the test protocol and further information on this task, go to Caroline Bowen’s website (URL is provided in Table 2–25). • The Test of Language Development Primary, Fifth Edition (TOLD-P5) (Newcomer & Hammill, 2019) Word Discrimination subtest measures the child’s ability to recognize differences in speech sounds by having them respond if two words are similar or different. The child is presented pairs of words that are either the same or differ by one phoneme.

Gross and Fine Motor Skills As noted in Chapter 1, studies have found children with CAS to be at high risk for co-occurring deficits in fine and gross motor skills. Because the SLP is often the first person to evaluate a child with suspected CAS, it is important to make some general observations of the coordination of the child’s gate during walking and running and coordination of the hands while the child is handling toys, cutting with scissors, and drawing or writing to make appropriate referrals to a physical therapist (PT) and/or occupational therapist (OT) if warranted. It may also be helpful to provide the parent the Developmental Coordination Disorder Questionnaire (DCDQ; Wilson & Crawford, 2007) for ages 5 to 15 years for additional information to pass onto the PT and OT to see if they qualify for additional assessment. The DCDQ is free, and the URL addresses can be found in Table 2–25.

Sensory There are several ways to check sensation, such as stimulus localization and two-point discrimination. However, noting whether the child demonstrates either hypersensitivity or reduced sensitivity (hyposensitivity) to sensory stimulation is often the most useful information for the clinician. A child with tactile hypersensitivity may resist tooth brushing or face washing or may express an unwillingness to accept certain food textures. These signs should be viewed

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   79

with caution, as they may be normal reactions of young children without tactile sensitivity differences. A child who exhibits hyposensitivity to tactile input may not be aware of food in the mouth, around the lips, or on the chin, or may appear unaware of drooling. Hyposensitivity also may lead to greater difficulty developing the somatosensory awareness required to support online speech production accuracy. The Sensory Profile-2 (Dunn, 2014) for birth to 14;11 is a tool that could be used to help us screen a child’s sensory processing patterns in all of their environments. However, it is best to consult with an OT for interpretation of results and recommendations for therapy. A URL to an online sensory checklist can be found in Table 2–25.

Social-Emotional Well-Being As discussed in Chapter 1, when a child has a severe communication disorder, it can impact their lives in many ways. It is well-documented that children with communication disorders are at higher risk for being bullied and feeling isolated (van den Bedem et al., 2018). When getting to know a child during the initial assessment, we may ask about their experiences with school, clubs, family, and friends to get a sense of how fully they are included in all of their communication circles. However, we may not get complete answers, as it takes time to establish trust to discuss these sensitive topics. Social-emotional well-being is an ongoing concern for many children, regardless of communication skills. Using good listening skills and creating a safe and brave space in our therapy session will allow us to stay connected and share concerns with parents and related professionals when they arise.

Interpretation of Evaluation Findings When the formal and informal elements of the speech and language evaluation have been completed and the data and findings are analyzed, a diagnosis (or diagnoses) may be made, and an appropriate treatment plan developed. A child is rarely ever only apraxic, so this should not be the only diagnosis listed. When we write the report, we want to be mindful of the whole child, as depicted in Figure 2–5. In other words, what is getting in the way of their communicative success, and what can we (SLPs, teachers, other therapists, family members, community) do to improve upon this success. When reporting the assessment findings, the following sequence is recommended: 1. Describe the purpose of the evaluation including who made the referral and why. 2. Summarize the case history in a manner that provides rationale for the evaluation and the areas that were assessed. 3. Describe the child’s overall demeanor (e.g., shy, hesitant, clingy with the parent, easily engaged, slow to warm up). With a young child, describe the child’s play, modes of communication, and responsiveness to attempts to interact. 4. Summarize results of the SFA in a way that provides evidence for the diagnosis or diagnoses you have determined from each part of your assessment. For example, did your findings from the SFA assessment reveal any signs of dysarthria, CAS, or NVOA? If so, what were they. If not, state “no signs of ____ were observed.” From the formal articulation/phonology test, provide results indicating evidence for an

80   Here’s How to Treat Childhood Apraxia of Speech

Figure 2–5.  Factors contributing to the child’s overall communicative success.

articulation or expressive phonological impairment and list the active phonological processes. If the child was unable to do a formal articulation test, provide the sound and syllable shape inventory gathered from informal assessment. 5. Assuming the child was referred for an assessment because of concern with CAS, results from the motor speech portion of the exam will be a key component of the report. Here you will want to provide the measures from the tasks that provided evidence of CAS, such as inconsistency of errors, disordered prosody, poorcoarticulation, segmented syllables, intrusive schwa, and so on. If there was no evidence of CAS, you will want to be clear to state that as well. If CAS was present, provide the level of phonetic and phonotactic complexity the child broke down at and include what cues helped the child improve. For example, “John was able to produce Vs, CVs, and VCs in two-syllable utterances with early developing sounds in direct imitation. He needed simultaneous and tactile cueing to correctly produce CVCs and three-syllable utterances.” Knowing where the child was successful with cuing will guide your recommendations that address improving the child’s sensory motor skills. 6. The next section should address all areas related to language and literacy. For young children, this may be based on informal observations, especially for the expressive language portion. Depending on the age of the child, results from phonological awareness and literacy measures should also be included. Since it is not always possible to assess all areas of concern in the diagnostic session, you could include a statement in your recommendations to assess the other areas you noted of concern at another time. Note additional concerns related to gross and fine motor, sensory issues/preferences, behavior, and social-emotional well-being.

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   81

7. Provide a list of recommendations that address all the areas of concern and referrals if warranted. 8. Last but not least, be sure to point out relative strengths of the child, as reading everything that is wrong with your child can be quite overwhelming. For example, was the child actively engaged and hardworking during the assessment? Did they demonstrate perseverance? Did they have a sense of humor? When writing attributes, look for the best possible way to describe them. For example, a child who was “hyperactive” could be referred to as enthusiastically energetic. Given that this is a lot to process, consider scheduling a follow-up call or visit to go through the assessment results after the parent has had time to absorb the information.  ase studies illustrating children with different communication profiles are available in the C online materials. A variety of online resources for assessment were referenced throughout this chapter. The URL or source for each of these assessment tools is listed in Table 2–25.

Table 2–25.  Online Resources for Screening and Assessment Tools Area of Assessment

Source and URL

ASD screener

Autism Navigator https://autismnavigator.learnercommunity.com/Files/Org/ b7feabe6ed9e4713b02511fc0003214c/site/16-Early-Signs-of-AutismChecklist.pdf

Symbolic play scale

Revised Concise Symbolic Scale (Westby, 2000) https://www.smartspeechtherapy.com/wp-content/uploads/2017/07/ Revised-Concise-Symbolic-Play-Scale.pdf

ASHA’s hearing screening guidelines

https://www.asha.org/practice-portal/professional-issues/childhoodhearing-screening/#collapse_1

Articulation assessments and word lists in other languages

https://www.csu.edu.au/research/multilingual-speech/speechassessments

Measuring inconsistency

Jenya Iuzzini-Seigel, PhD, CCC-SLP provides great resources for explaining and measuring inconsistency, in addition to other CASrelated topics on her lab’s Instagram account (@maquette_CML_lab); https://campsite.bio/marquette_cml_lab See links for “Buy Bobby a Puppy” and “Calculating ISP” Another link to Iuzzini’s ISP tutorial: https://drive.google.com/file/d/12r QeWqCh9QqZAzHuEcJJuL3R0Nu5L7Kw/view

Picture description

Park Play:  A picture description task for assessing childhood motor speech disorders (Patel & Connaghan, 2014) https://www.tandfonline.com/doi/full/10.3109/17549507.2014.894124​ ?scroll=top&needAccess=true continues

82   Here’s How to Treat Childhood Apraxia of Speech

Table 2–25.  continued Area of Assessment

Source and URL

Connected speech analysis

Protocol for Connected Speech Transcription of Children with Speech Disorders (Barrett et al., 2020) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6940559/

Multisyllabic word lists

Ten clinically useful words from Caroline Bowen’s website https://speech-language-therapy.com/index.php?option=com_content​ &view=article&id=46 Single-word test of polysyllables (Gozzard et al., 2006) https://www.academia.edu/22333231/Children_s_productions_of_ polysyllables

Intelligibility

The Preschool Speech Intelligibility Measure (Morris, Wilcox, & Schooling, 1995), Appendix B https://doi.org/10.1044/1058-0360.0404.22 Beginner’s Intelligibility Test and Monsen-Indiana University Sentences available in “Relationships between speech intelligibility and word articulation scores in children with hearing loss” (Ertmer, 2010), Appendixes A and B https://doi.org/10.1044/1092-4388(2010/09-0250)

Software for calculating intelligibility

Pronunciation Coach 3D software https://rose-medical.com//pronunciation-coach-3d.html

Intelligibility/ comprehensibility

Intelligibility in Context Scale available in 60 languages (McLeod et al., 2012b) http://www.csu.edu.au/research/multilingual-speech/ics

Phonological awareness

The Phonological Awareness Screening Test (Kilpatrick, 2019) https://www.thepasttest.com/

Speech perception

The Locke Speech Perception-Speech Production Task is available on Caroline Bowen’s website. Directions for task: https://www.speech-language-therapy.com/index.php?option=com_ content&view=article&id=46:speechax&catid=9:resources&Itemid=117 Protocol: https://www.speech-language-therapy.com/pdf/locketask.pdf

Gross motor

Developmental Coordination Disorder Questionnaire (DCDQ) https://www.dcdq.ca/uploads/pdf/DCDQAdmin-Scoring-02-20-2012.pdf

Sensory

Sensory checklist https://www.sensorysmarts.com/sensory-checklist.pdf

Hearing

Childhood Hearing Screening https://www.asha.org/practice-portal/professional-issues/childhoodhearing-screening/#collapse_1

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   83

References Allison, K. (2020). Measuring speech intelligibility in children with motor speech disorders. Perspectives of the ASHA Special Interest Groups 2, 5(4), 809–820. https://doi.org/10.1044/2020_PERSP-19-00110 American Speech-Language-Hearing Association (n.d.). Childhood apraxia of speech [Practice portal]. http:// www.asha.org/Practice-Portal/Clinical-Topics/Child hood-Apraxia-of-Speech/ American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical report]. https://doi.org/10.1044/policy.TR2007-00278 Audacity [Computer Software]. (2021). https://www. audacityteam.org/ Barrett, C., McCabe, P., Masso, S., & Preston, J. (2020). Protocol for the connected speech transcription of children with speech disorders: An example from childhood apraxia of speech. Folia Phoniatrica et Logopaedica, 72(2), 152–166. https://doi.org/10.1159/​ 000500664 Bayley, N., & Aylward, G. (2019). Bayley Scales of Infant and Toddler Development Screening Test (3rd ed.). Pearson. https://www.pearsonassessments.com/store/us​ assessments/en/Store/Professional-Assessments/Cog​ nition-%26-Neuro/Brief/Bayley-Scales-of-Infant-andToddler-Development-Screening-Test-%7C-Third-Edition/p/100000108.html Benway, N. R., & Preston, J. L. (2020). Differences between school-age children with apraxia of speech and other speech sound disorders on multisyllable repetition. Perspectives of the ASHA Special Interest Groups, 5(4), 794–808. https://doi.org/10.1044/2020​ _​PERSP-19-00086 Bravo, L. (2017). Bla Bla Bla (Version 2.0) [Mobile app]. App Store. https://apps.apple.com/us/app/ bla-bla-bla/id430815432 Bzoch, K. R., League, R., & Brown, V. L. (2003). Receptive-Expressive Emergent Language Test, Third edition (REEL-3). Pearson. Carlock, G. S., Fischer, T., Lynch, M. E., Potter, N. L., Coles, C. D., Epstein, M. P., . . . Fridovich-Keil, J. L. (2019). Developmental outcomes in Duarte galactosemia. Pediatrics, 143(1), e20182516. https://doi.org/​ 10.1542/peds.2018-2516 Caruso, A. & Strand, E. (1999). Clinical management of motor speech disorders in children. Thieme. Clark, H. M., & Baas, B. S. (2021). CAS: Similar hoofbeats, but not a horse. ASHA Leader, 26(1), 46–53. Davis, B., & Velleman, S. (2000). Differential diagnosis and treatment of developmental apraxia of speech

in infants and toddlers. Infant-Toddler Intervention, 10(3), 177–192. Dodd, B., Hua, Z., Crosbie, S., Holm, A., & Ozanne, A. (2002). Diagnostic evaluation of articulation and phonology. Pearson. https://www.pearsonassessments.com/ store/usassessments/en/Store/Professional-Assess​ ments/Speech-%26-Language/Diagnostic-Evalua​ tion-of-Articulation-and-Phonology/p/100000295. html Duchow, H., Lindsay, A., Roth, K., Schell, S., Allen, D., & Boliek, C. A. (2019). The co-occurrence of possible developmental coordination disorder and suspected childhood apraxia of speech. Canadian Journal of Speech-Language Pathology and Audiology, 43(2), 81–93. Dunn, W. (2014). Sensory Profile 2. Pearson. https:// www.pearsonassessments.com/store/usassessments/ en/Store/Professional-Assessments/Motor-Sensory/ Sensory-Profile-2/p/100000822.html Ertmer, D. J. (2010). Assessing speech intelligibility in children with hearing loss: Toward revitalizing a valuable clinical tool. Language Speech and Hearing Services in Schools, 42(1), 52–58. https://pubs.asha.org/ doi/full/10.1044/0161-1461%282010/09-0081%29 Fenson, L. (2007). MacArthur-Bates Communicative Development Inventories. Paul H. Brookes. Fletcher, S. (1972). Time-by-count measurement of diadochokinetic syllable rate. Journal of Speech and Hearing Research, 15(4), 763–770. https://doi.org/10​ .1044/​jshr.1504.763 Fudala, J. B., & Stegall, S. (2017). Arizona Articulation and Phonology Scale, Fourth edition. Western Psychological Services. https://www.proedinc.com/Prod​ ucts/14723/arizona4-arizona-articulation-and-pho​ nology-scalefourth-edition.aspx Glaspey, A. (2021). Glaspey Dynamic Assessment of Phonology. Academic Therapy Publications. https:// www​. academictherapy.com/detailATP.tpl?eqsku​ datarq=2244-6 Glennen, S. (2014). A longitudinal study of language and speech in children who were internationally adopted at different ages. Language, Speech, and Hearing Services in Schools, 45, 185–203. https://doi​ .org/​10​.1044/​2014_LSHSS-13-0035 Goldman, R., & Fristoe, M. (2015). Goldman-Fristoe Test of Articulation-3. Pearson. Gozzard, H., Baker, E., & McCabe, P. (2006). Children’s productions of polysyllabic words. ACQuiring Knowledge in Speech, Language and Hearing, 8, 113–116.

84   Here’s How to Treat Childhood Apraxia of Speech https://www.academia.edu/22333231/Children_s_ productions_of_polysyllables Gozzard, H., Baker, E. & McCabe, P. (2008). Requests for clarification and children’s speech responses: Changing “pasghetti” to “spaghetti.” Child Language Teaching and Therapy, 24, 249–263. https:// doi.org/10.1177%2F0265659008096292 Groenen, P., Maassen, B., Crul, T., & Thoonen, G. (1996). The specific relation between perception and production errors for place of articulation in developmental apraxia of speech. Journal of Speech, Language, and Hearing Research, 39, 468–482. https:// doi.org/10.1044/jshr.3903.468 Hayden, D., & Namasivayam, A. K. (2021). Verbal Motor Production Assessment for Children–Revised (VMPAC-R) [Mobile application software]. https://vmpac-r.com/ Hayden, D., & Square, P. (1999). Verbal Motor Production Assessment for Children. Psychological Corporation [out of print]. Hodson, B. (2004). Hodson Assessment of Phonological Patterns (3rd ed.). Pro-Ed. https://www.proedinc.com/ Products/11550/happ3-hodson-assessment-of-pho nological-patternsthird-edition.aspx Ingram, S. B., Reed, V. A., & Powell, T. W. (2019). Vowel duration discrimination of children with childhood apraxia of speech: A preliminary study. American Journal of Speech-Language Pathology, 28(2S), 857–874. https://doi.org/10.1044/2019_AJSLP-MSC18-​18-0113 Iuzzini, J., & Forrest, K. (2010). Evaluation of a combined treatment approach for childhood apraxia of speech. Clinical Linguistics and Phonetics, 24(4–5), 335–345. https://doi.org/10.3109/02699200903581083 Iuzzini-Seigel, J. (2019). Motor performance in children with childhood apraxia of speech and speech sound disorders. Journal of Speech, Language, and Hearing Research, 62(9), 3220–3233. https://doi.org/​ 10.1044/2019_JSLHR-S-18-0380 Iuzzini-Seigel, J. (2021, May 4). Assessment of childhood apraxia of speech [Webinar]. SPEECHPATHOLOGY. COM. https://www.speechpathology.com/slp-ceus/ course/assessment-childhood-apraxia-speech-9705 Iuzzini-Seigel, Allison, K. M., & Stoeckel, R. (2022). A tool for differential diagnosis of childhood apraxia of speech and dysarthria in children: A tutorial. Language, Speech, and Hearing Services in Schools. https:// doi.org/10.1044/2022_LSHSS-21-00164 Iuzzini-Seigel, J., Hogan, T. P., & Green, J. R. (2017). Speech inconsistency in children with childhood apraxia of speech, language impairment, and speech delay: Depends on the stimuli. Journal of Speech, Language, and Hearing Research, 60(5), 1194–1210. https://doi.org/10.1044/2016_JSLHR-S-15-0184 Iuzzini-Seigel, J., & Murray, E. (2017). Speech assessment in children with childhood apraxia of speech.

Perspectives of the ASHA Special Interest Groups, 2(2), 47–60. https://doi.org/10.1044/persp2.SIG2.47 Jenista, J. (1997). Russian children and medical records. Adoption Medical News, 3(7), 1–8. Kahn, M. L., & Lewis, N. P. (2015). Khan-Lewis Phonological Analysis (3rd ed.). Pearson. https://www​.pear​son​ assessments.com/store/usassessments/en/Store/Pro​ fessional-Assessments/Developmental-Early-Child​ hood/Khan-Lewis-Phonological-Analysis-%7 ​ C -​ Third-​Edition/p/100001242.html Kaufman, N. (1995). Kaufman Speech Praxis Test for Children. Wayne State University Press. Kent, R. D., Kim, Y., & Chen, L. (2021). Oral and laryngeal diadochokinesis across the life span: A scoping review of methods, reference data, and clinical applications. Journal of Speech, Language, and Hearing Research, 1–50. https://doi.org/10.1044/2021_ JSLHR-21-00396 Kent, R., & Rountrey, C. (2020). What acoustic studies tell us about vowels in developing and disordered speech. American Journal of Speech-Language Pathology, 29, 1749–1778. https://doi.org/10.1044/2020_ AJSLP-19-00178 Kilpatrick, D. A. (2019). Phonological Awareness Screening Test (PAST). https://www.thepasttest.com/ Levy, E. S., Chang, Y. M., Hwang, K., & McAuliffe, M. J. (2021). Perceptual and acoustic effects of dual-focus speech treatment in children with dysarthria. Journal of Speech, Language, and Hearing Research, 64(6S), 2301–2316. https://doi.org/10.1044/2020_JSLHR-2000301 Lewis, B. A., Freebairn, L. A., Hansen, A. J., Iyengar, S. K., & Taylor, H. G. (2004). School-age follow-up of children with childhood apraxia of speech. Language, Speech, and Hearing Services in Schools, 35(2), 122– 140. https://doi.org/10.1044/0161-1461(2004/014) Lindamood, P. C., & Lindamood, P. (2004). Lindamood Auditory Conceptualization Test (3rd ed.). Pro-Ed. https://www.proedinc.com/Products/10980/lac3-lin​ damood-auditory-conceptualization-testthird-edi​ tion​.aspx Lipkin, P. H., & Macias, M. M. (2020). Promoting optimal development: Identifying infants and young children with developmental disorders through developmental surveillance and screening. Pediatrics, 145, e20193449. https://doi.org/10.1542/peds​ .2019-3449 Locke, J. L. (1980). The inference of speech perception in the phonologically disordered child. Part II: Some clinically novel procedures, their use, some findings. Journal of Speech and Hearing Disorders, 45, 445–468. https://doi.org/10.1044/jshd.4504.445 Maassen, B., Groenen, P., & Crul, T. (2003). Auditory and phonetic perception of vowels in children with

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   85 apraxic speech disorders. Clinical Linguistics & Phonetics, 17(6), 447-467. https://doi.org/10.1080/​026​9​ 920031000070821 Maenner, M., Shaw, K., Bakian, A.V., Bilder, D., Durkin, M., Esler, A., . . . Cogswell, M. E. (2021). Prevalence and characteristics of autism spectrum disorder among children aged 8 years — Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2018. Morbidity and Mortality Weekly Report Surveillance of Summaries, 70(11), 1–16. http:// dx.doi.org/10.15585/mmwr.ss7011a1 Masso, S., McLeod, S., & Baker, E. (2018). Tutorial: Assessment and analysis of polysyllables in young children language. Language, Speech, and Hearing Services in Schools, 49, 42–58. https://doi.org/​10.10​ 44/2017_LSHSS-16-0047 McLeod, M. (2020). Intelligibility in context scale: Crosslinguistic use, validity, and reliability. Speech, Language and Hearing, 23(1), 9–16. https://doi.org/​ 10.1080/2050571X.2020.1718837 McLeod, S., & Crowe, K. (2018). Children’s consonant acquisition in 27 languages. A cross-linguistic review. American Journal of Speech-Language Pathology, 27, 1546–1571. https://doi.org/10.1044/2018_AJSLP-170100 McLeod, S., Harrison, L. J., & McCormack, J. (2012a). Intelligibility in Context Scale. Charles Sturt University. http://www.csu.edu.au/research/multilingual-speech/​ ics McLeod, S., Harrison, L. J., & McCormack, J. (2012b). The intelligibility in context scale: Validity and reliability of a subjective rating measure. Journal of Speech, Language, and Hearing Research, 55(2), 648– 656. https://doi.org/10.1044/1092-4388(2011/100130) McLeod, S., & Verdon, S. (2014). A review of 30 speech assessments in 19 languages other than English. American Journal of Speech-Language Pathology, 23(4), 708– 723. https://doi.org/10.1044/2014_ajslp-13-0066 Monsen, R. B. (1981). A usable test for the speech intelligibility of deaf talkers. American Annals of the Deaf, 126, 845–852. https://doi.org/10.1353/aad.2012​ .1333 Morley, M., Court, D., & Miller, H. (1954). Developmental dysarthria. British Medical Journal, 1, 8. https:// doi.org/10.1136/bmj.1.4852.8 Morris, S. R., Wilcox, K.A., & Schooling, T. L. (1995). The preschool speech intelligibility measure. American Journal of Speech-Language Pathology, 4(4), 22–28. https://doi.org/10.1044/1058-0360.0404.22 Murray, E., Iuzzini-Seigel, J., Maas, E., Terban, H., & Ballard, K. J. (2021). Differential diagnosis of childhood apraxia of speech compared to other speech sound disorders: A systematic review. American Jour-

nal of Speech-Language Pathology, 30(1), 279–300. https://doi.org/10.1044/2020_AJSLP-20-00063 Murray, E., McCabe, P., Heard, R., & Ballard, K. J. (2015). Differential diagnosis of children with suspected childhood apraxia of speech. Journal of Speech, Language, and Hearing Research, 58(1), 43–60. https:// doi.org/10.1044/2014_JSLHR-S-12-0358 Nelson, N., Plante, E., Helm-Estabrooks, N., & Hotz, G. (2016). Test of Integrated Language and Literacy Skills. Brookes Publishing. https://products.brookespub​ lishing.com/Test-of-Integrated-Language-and-Liter​ acy-Skills-TILLS-Examiners-Kit-P1271.aspx Newcomer, P. L., & Hammill, D. D. (2019). Test of Language Development: Primary (5th ed.). Western Psychological Services. https://www.wpspublish.com/​ told-p5-test-of-language-developmentprimary-fifth-​ edition Nijland, L. (2009). Speech perception in children with speech output disorders. Clinical Linguistics & Phonetics, 23(3), 222–239. https://doi.org/10.1080/0269​92​ 00802399947 Osberger, M. J., Robbins, A., Todd, S., & Riley, A. (1994). Speech intelligibility of children with cochlear implants. Volta Review, 96(5), 169–180. Overby, M., Belardi, K., & Schreiber, J. (2020). A retrospective video analysis of canonical babbling and volubility in infants later diagnosed with childhood apraxia of speech. Clinical Linguistics & Phonetics, 34(7), 634–651. https://doi.org/10.1080/02699206​ .2019.1683231 Overby, M., & Caspari, S. S. (2015). Volubility, consonant, and syllable characteristics in infants and toddlers later diagnosed with childhood apraxia of speech: A pilot study. Journal of Communication Disorders, 55, 44–62. https://doi.org/10.1016/j.jcom​ dis.2015.04.001 Overby, M. S., Caspari, S. S., & Schreiber, J. (2019). Volubility, consonant emergence, and syllabic structure in infants and toddlers later diagnosed with childhood apraxia of speech, speech sound disorder, and typical development: A retrospective video analysis. Journal of Speech, Language, and Hearing Research, 62, 1657–1675. https://doi.org/10.1044/2019_JSLHR-S-​ 18-0046 Parks Warshaw, S. (2013). Hawaii Early Learning Profile (HELP: 0-3). VORT Corporation. https://www.vort​ .com/product.php?productid=5 Patel, R., & Connaghan, K. (2014). Park play: A picture description task for assessing childhood motor speech disorders. International Journal of Speech-Language Pathology, 16(4), 337–343. https://doi.org/10​ .3109/17549507.2014.894124 Potter, N. L. (2004). Oral/speech and manual motor development in preschool children (Publication No. 3155158)

86   Here’s How to Treat Childhood Apraxia of Speech [Doctoral dissertation, University of Wisconsin– Madison]. ProQuest Dissertations and Theses Global. Potter, N. L., & Skinder-Meredith, A. E. (2022). Structural Functional Praxis Exam [Unpublished data]. Prizant, B., & Wetherby, A. (2003). Communication and Symbolic Behavior Scales (CSBS). Brookes Publishing. https://brookespublishing.com/product/csbs/ Rvachew, S. & Brosseau-Lapré, F. (2021). Speech perception intervention. In A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), Interventions for speech sound disorders in children (2nd ed., pp. 201–224). Brookes Publishing. Sacrey, L.-A. R., Bryson, S., Zwaigenbaum, L., Brian, J., Smith, I. M., Roberts, W., . . . Garon, N. (2018). The Autism Parent Screen for Infants: Predicting risk of autism spectrum disorder based on parent-reported behavior observed at 6–24 months of age. Autism: The International Journal of Research and Practice, 22(3), 322–334. doi:10.1177/1362361316675120 Seikel, A., Konstantopoulos, K., & Drumright, D. (2020). Neuroanatomy and neurophysiology for speech and hearing sciences. Plural Publishing. Shriberg, L. D., Austin, D., Lewis, B. A., McSweeney, J. L., & Wilson, D. L. (1997). The percentage of consonants correct (PCC) metric: Extensions and reliability data. Journal of Speech, Language, and Hearing Research, 40, 708–722. https://doi.org/10.1044/jslhr.4004.708 Shriberg, L. D., & Kwiatkowski, J. (1982). Phonological disorders III: A procedure for assessing severity of involvement. Journal of Speech and Hearing Disorders, 47, 256–270. https://doi.org/10.1044/jshd.4703.256 Shriberg, L. D., Potter, N. L., & Strand, E. A. (2009, November). Childhood apraxia of speech in children and adolescents with galactosemia. [Conference presentation]. American Speech-Language-Hearing Association National Convention, New Orleans, LA. Shriberg, L. D., Strand, E. A., Fourakis, M., Jakielski, K. J., Hall, S. D., Karlsson, H. B., . . . Wilson, D. L. (2017). A diagnostic marker to discriminate childhood apraxia of speech from speech delay: IV. The Pause Marker Index. Journal of Speech, Language and Hearing Research, 60(4), S1153–S1169. https://doi​ .org/​10.1044/2016_JSLHR-S-16-0149 Shriberg, L. D., Strand, E., Jakielski, K. J., & Mabie, H. L. (2019). Estimates of the prevalence of speech and motor speech disorders in persons with complex neurodevelopmental disorders. Clinical Linguistics & Phonetics, 33(8), 707–736. https://doi.org/10.1080/​ 02699206.2019.1595732 Skinder, A., Strand, E., & Mignerey, M. (1999). Perceptual and acoustic analysis of lexical and sentential stress in children with developmental apraxia of speech. Journal of Medical Speech Pathology, 7, 133–144.

Skinder-Meredith, A., & Fish, M. (2022). Dynamic Multisyllabic Word Probe [Unpublished]. Skoog, K. & Maas, E. (2020). Predicting intelligibility: An investigation of speech sound accuracy in childhood apraxia of speech, CommonHealth, 1(2), 44–56. https://doi.org/10.15367/ch.v1i2.397 Soriano, J. U., Olivieri, A., & Hustad, K. C. (2021). Utility of the Intelligibility in Context Scale for predicting speech intelligibility of children with cerebral palsy. Brain Sciences, 11(11), 1540. https://www.md​ pi.com/2076-3425/11/11/1540 Strand, E. A. (2017). Appraising apraxia: When a speech-sound disorder is severe, how do you know if it’s childhood apraxia of speech? The ASHA Leader. https://doi.org/10.1044/leader.FTR2.22032017.50 Strand, E. A., & McCauley, R. J. (2019). Dynamic Evaluation of Motor Speech Skill (DEMSS) manual. Brookes Publishing. https://products.brookespublishing.com/​ Dynamic-Evaluation-of-Motor-Speech-Skill-DEMSS-​ Manual-P1100.aspx Thoonen, G., Maassen, B., Gabreels, F., & Schneider, R. (1999). Validity of maximum performance tasks to diagnose motor speech disorders in children. Clinical Linguistics & Phonetics, 13(1), 1–23. https://doi.org/​ 10.1080/026992099299211 Torgensen, J. K., & Bryant, B. R. (2004). Test of Phonological Awareness, Second edition: PLUS (TOPA-2+). Pro-Ed. https://www.proedinc.com/Products/11880/ topa2-test-of-phonological-awarenesssecond-edi​ tion-plus.aspx van den Bedem, N. P., Dockrell, J. E., van Alphen, P. M., Kalicharan, S. V., & Rieffe, C. (2018). Victimization, bullying, and emotional competence: Longitudinal associations in (pre)adolescents with and without developmental language disorder. Journal of Speech, Language, and Hearing Research, 61(8), 1–17. https:// doi.org/10.1044/2018_JSLHR-L-17-0429 Wagner, R., Torgesen, J., Rashotte, C., & Pearson, N. (2013). Comprehensive Test of Phonological Processing, Second edition (CTOPP-2). Pearson. https://www​ .pearsonassessments.com/store/usassessments/en/ Store/Professional-Assessments/Speech-%26-Lan​ guage/Comprehensive-Test-of-Phonological-Pro​ cessing-%7C-Second-Edition/p/100000737.html Westby, C. (1980). Assessment of cognitive and language abilities through play. Language, Speech, and Hearing Services in Schools, 11, 154–168. https://doi​ .org/10.1044/0161-1461.1103.154 Wilson, B. N., & Crawford, S. G. (2007). Developmental Coordination Disorder Questionnaire. https://www​ .dcdq.ca/ Yorkston, K., Beukelman, D., & Hakel, M. (1996). Sentence Intelligibility (SIT) Standard [Electronic version].

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   87 https://www.madonna.org/payments/products/ sit-​standard Yorkston, K., Strand, E., & Kennedy, M. (1996). Comprehensibility of dysarthric speech: Implications for assessment and treatment planning. American Journal of Speech-Language Pathology, 5(1), 55–66. https://doi.org/10.1044/1058-0360.0501.55

Zuk, J., Iuzzini-Seigel, J., Cabbage, K., Green, J., & Hogan, T. (2018). Poor speech perception is not a core deficit of childhood apraxia of speech: Preliminary findings. Journal of Speech, Language, and Hearing Research, 61, 583–592. https://doi.org/10.1044/​ 2017_JSLHR-S-16-0106

88   Here’s How to Treat Childhood Apraxia of Speech

APPENDIX 2–A

Case History for Young Children Name _______________________________________  Date _______________ Birth Date _______________  Chronological Age ________ Family and developmental History Family history of speech, language, and/or literacy disorders Genetic testing results or other diagnosis Pregnancy and birth history: Age of attainment of motor milestones. turning over ______________ crawling ______________ sitting ______________ walking _______________ Has your child been diagnosed with, or do you have concerns with any of the following areas related to development? _____ Clumsy and poor coordination for fine motor and gross motor activities _____ Possible autism spectrum disorder (ASD) _____ Delayed auditory comprehension _____ Delayed expressive language _____ Dysarthria (weakness, limited range of motion, and lack of coordination of the structures used for speech) _____ Feeding and swallowing concerns _____ Drooling _____ Sensory Issues (dislikes specific sounds, textures, touch, lighting, etc.) _____ Behavioral Concerns (difficult to soothe, highly anxious in new situations, dislikes change in routine, frequent temper tantrums, aggressive behavior, etc.) History of Vocalizations, Babbling, and First Words As an infant was your child quiet with limited babbling? What sounds did they make?

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   89

Does it seem like your child doesn’t have as many sounds as their peers? What sounds does your child produce? At what age did your child produce their first consonant? At what age did your child say their first word? At what age was your child able to say 10–15 different words that they use regularly? Provide examples of how your child says their most frequently occurring words (e.g., “wawa” for water). Does your child use a variety of intonation patterns? In other words, can they change their voice from loud to quiet, high to low, express different emotions? Is it common for your child to say a word and then never say it again? Does your child ever appear to be groping for sounds? Does your child have difficulty combining different syllables? Does your child have more difficulty with volitional than automatic nonspeech oral motor behaviors? Does your child use idiosyncratic signs for functional communication?

90   Here’s How to Treat Childhood Apraxia of Speech

APPENDIX 2–B

Observations of Vocalizations and Communication Attempts Name _______________________________________  Date _______________ Birth Date _______________  Age ________ Phonetic inventory

: Syllable shape repertoire:

Primary modes of communication: (e.g., gestures, vocalizations, word approximations)

Circle the communicative intents observed: request for help labeling request for items describing request for activities commenting request for attention expressing feelings refusing or rejecting items refusing or rejecting activities Mark the characteristics observed during the evaluation. Limited resonant (speech-like) vocalizations Limited phonetic inventory of consonants and vowels Predominant use of simple syllable shapes (V, CV, CVCV, VC) Early sound productions restricted to Early Eight (/p, b, j, n, w, d, p, h/) Use of gestures and signs Receptive language appears higher than expressive language

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   91

APPENDIX 2–C

Case History for Preschoolers and Young School Age Child’s name: _____________________________ DOB: ________________________ Parent/Guardian’s name (s): ____________________________ Tell me about a typical day with your child. Does your child have any other diagnosis besides apraxia of speech? Does your child have any other/related medical concerns? Does your child have any food restrictions? Has your child had a standardized articulation test? If so, which one, and what were the results? How does your child get your attention? Words? Sounds? Gestures? What type of gestures? How does your child communicate wants and needs? Speaking? Gestures? How many words does your child produce? Are they nouns, verbs, adjectives? Circle yes (Y) or no (N) and add any additional relevant information. Y N  Does your child imitate speech sounds? Y N  Does your child combine two or more words in a phrase? (i.e., more cookie, car bye-bye) Y N  Does your child count or say the alphabet? Y N  Does your child use simple grammatical endings (verb -ing, plural -s)? Y N  Does your child answer simple/follow commands (i.e., get your cup)? Y N  Does your child take turns in conversation or play? What are some words or attempts at words that your child says?    continues

92   Here’s How to Treat Childhood Apraxia of Speech

Appendix 2–C.  continued

What sounds does your child make? (circle all) Sound

Example Words

Sound

Example Words

p

ppy, cup p pin, happ

sh

ship, cial, rush sh sh speci

b

bbit, knob b bake, rabb

h

head hut, foreh

t

tan, hottel, satt

ch

cheese, nach chos, beach ch ch

d

da, food d dim, sod

j

jug, mag gic, age ge

k

cat, buck cket, musicc

w

way wood, aw

g

gum, ag gain, dog g

y

yell, roy yal

f

ffee, rough gh fun, coff

l

look, collor, fell ll

v

vote, ov ven, have ve

r

run, carr rrot, hairr

th (voiceless)

thin, noth thing, tooth th th

m

make, summ mmer, same me

th (voiced)

that, moth ther, breathe the th

n

new, sunn nny, mean n

s

sunny, merccy, chase se

ng

long nger, song ng, ring ng

z

zip, eassy, peass

How intelligible is your child’s speech to strangers? (circle one) Unintelligible      25%–50%      50%–75%      75%–100% Are there are any phrases they say? Do they put two words together? Three words?    With whom does your child spend a majority of the day? Does your child initiate play with others by using language (e.g., “do you want to play with me?”)? What kinds of play activities does your child engage in?

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   93

Does your child play computer/tablet/phone games? If yes, list games. What are some shows/movies/toys your child especially enjoys? What are some games or activities that seem to be especially motivating to your child? Are there any other positive reinforcements or motivating techniques your child responds well to? What are some words/phrases that you would like your child to work on or be able to say? 1. _________________________________________________________________________ 2. _________________________________________________________________________ 3. _________________________________________________________________________ 4. _________________________________________________________________________ What letter sounds can your child identify, and what letter sounds can they say? Circle the ones you think they understand, and underline the ones they can say. A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

Does your child recognize sounds in words? Does your child recognize letters in words? Language — Mark Y for YES, N for no, and U for UNSURE. _______ uses language to express emotion _______ follows two- and three-part commands _______ tells two events in chronological order _______ understands concepts related to time (e.g., yesterday, today, tomorrow) _______ counts to 10

continues

94   Here’s How to Treat Childhood Apraxia of Speech

_______ names days of the week in order _______ uses conjunctions (e.g., and, or, but) _______ uses past tense and future tense appropriately _______ asks how questions _______ follows instructions given to a group _______ understands left and right Phonological Awareness — Mark Y for YES, N for no, and U for UNSURE. _______ can your child tell you the beginning sounds of words (e.g., popcorn begins with p)? _______ does your child know the beginning sounds of their name? _______ can your child identify the first sound in a word (e.g., Which two words start with the same sound? Pot- talk- pig ) _______ can your child identify the last sound in a word (e.g., Which two words end with the same sound? cup- lip-run) _______ can your child recognize simple rhymes (e.g., Which two words rhyme? fat-foot-cat) _______ can your child make a rhyme? _______ can your child clap the number of syllables in a multisyllabic word (e.g., cowboy has two parts, cow and boy)? _______ can your child add or delete phonemes from a word (e.g., “say cat without the c sound . . . at”)? Is there any family history of reading disabilities?  Yes/No/Unsure Literacy/Writing — Mark Y for YES, N for no, and U for UNSURE. _______ can your child identify the front of a book? _______ can your child identify the back of a book? _______ does your child show an interest in books? _______ does your child enjoy being read to? _______ does your child have a favorite book? _______ does your child notice print in their environment? (business signs, house items) _______ does your child understand that pictures in a book tell a story? _______ does your child read or pretend to read? _______ does your child make up stories?

2.  Assessment and Differential 1.  Understanding Diagnosis of Childhood Apraxia of Speech   95

_______ does your child know that adults read printed text when reading stories aloud? _______ does your child know that reading occurs from top to bottom? _______ does your child know that reading occurs from left to right? _______ does your child ask and/or answer questions about a story? _______ can your child predict events in a story using illustrations or already known facts? _______ does your child recognize their name in print? _______ does your child pretend to write? _______ does your child use real letters when writing? _______ does your child attempt to write real words, even if misspelled? _______ does your child attempt to copy words? _______ can your child write their first name?

96   Here’s How to Treat Childhood Apraxia of Speech

APPENDIX 2–D

Structure-Function-Praxis-Motor Speech Exam (Potter & Skinder-Meredith, 2022, unpublished) Name _____________________________  Date of Birth ___________  Date of Exam ___________ Examiner _____________________________  Age ___________ History regarding chewing, drooling, swallowing, oral aversion, sensory issues, TMJ issues, etc.    Structure & Tone (observe at rest)

Structure (STR) Cranial/facial symmetry Lips Ears Eyes Mandible Dentition Occlusion Tongue (symmetry at rest) Length of lingual frenulum Hard palate Velum

Comments

Within Functional Limits (WFL)

Deviant

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   97

Observations Relating to Tone

Absent

Present

Drooling Open-mouth posture

Oral Motor Function (OMF) Structure

Tongue — CN XII

Performance

WFL

MildModerately Impaired

Severely Impaired

Protrusion “Stick out your tongue.” Look for deviation to left or right and range of motion (ROM). Elevation “Can you touch your tongue to your nose?” (Or place a tongue depressor over the upper lip and say, “Touch the stick with your tongue.”) Tongue tip should elevate to the upper lip without lower lip/jaw assistance. Tongue wag “Can you move your tongue like mine?” Model tongue movement from corner to corner for three complete back-and-forth sequences. Observe child’s attempt for speed, coordination, and ROM. Lateral tongue strength “I’m going to try to push your tongue. Don’t let me.” With jaw approximately half open, have the child push against tongue depressor on each side. Note resistance. Lips — CN VII Pucker “Say (oo)” Look for symmetry and ROM. continues

98   Here’s How to Treat Childhood Apraxia of Speech

Appendix 2–D.  continued

Structure

Lips — CN VII Retraction “Say (ee)” Look for symmetry and ROM. Pucker to retraction “Say (oo-ee x 3)” Look for symmetry, ROM, and speed. Strength of lips pressed together “Bite your teeth together. Now press your lips together. I’m going to try to pull your lips apart, but don’t let me.” Apply upward pressure against upper two quadrants and downward pressure against lower two quadrants to check for resistance with a tongue depressor or gloved finger. If any weakness is observed, note which quadrant — upper right (UR), upper left (UL), lower right (LR), lower left (LL). Jaw — CN V Symmetry, ROM, and stability during jaw opening and closing “Open and close your jaw x 2.” Look for smooth movement, symmetry, appropriate excursion, and evidence of jaw sliding. Velum — CN IX and X Velar elevation during sustained “ah” “Say ah for 5 seconds. I’ll tell you when to start and stop.” Look for timing of movement, ROM, symmetry, and endurance. Velar elevation during staccato production of “ha” “Say ha-ha-ha.” Look for timing of movement, symmetry, and ROM.

Performance

WFL

MildModerately Impaired

Severely Impaired

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   99

Summary of findings:  Include observations of symmetry and tone of structures at rest and observations of range of motion, symmetry, speed, strength, and coordination during movement tasks.    

Assessment of Resonance, Phonation, Respiratory Support, and Articulation Resonance To assist with judgment of resonance use a listening tube or straw going from under one of the client’s nostrils to the listener’s ear or place a small mirror under the nostrils while they repeat the following stimuli. If the phrase is too difficult, have them repeat the syllable instead.

Normal

Hypernasal

Nasal Emissions

Hyponasal

Buy Bobby a puppy Pa pa pa Seesaw, Seesaw, Seesaw Sa sa sa Mama made lemonade Ma ma ma Spontaneous speech

continues

100   Here’s How to Treat Childhood Apraxia of Speech

Appendix 2–D.  continued

Phonation and Respiration Use a stopwatch or sound editing software (e.g., Audacity) to time the number of seconds for each trial. Phonation-Respiration Duration

Trial 1

Trial 2

Trial 3

Longest of Three Trials

Maximum exhalation duration (MED) Have a cup of water with a straw positioned so the low end is 5 cm below the surface of the water. You may need to plug the child’s nose to avoid air escape. “Blow through the straw and make bubbles for as long as you can in one breath. I’ll go first.” Maximum phonation duration (MPD) “Say /ah/ for as long as possible. I’ll go first.” Phonation-CN X *You can use your observations of sustained phonation from the last task, rather than having the child sustain phonation again. Observations of Phonatory Quality and Control Sustained Phonation* “Say /ah/ steadily for as long as you can. I’ll go first.”

Normal

Abnormally High Or Low Pitch

Reduced Pitch Range

Strained/ Strangled

Breathy

Rough

Tremor/ Flutter/ Pitch Instability

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   101

Observations of Phonatory Quality and Control

Normal

Abnormally High Or Low Pitch

Reduced Pitch Range

Strained/ Strangled

Breathy

Rough

Tremor/ Flutter/ Pitch Instability

Pitch Range “Sing ah, then go as low as you can. Sing ah again and then go as high as you can. I’ll go first.” Spontaneous Speech Observe the child’s pitch range and voice quality during a connected speech sample. *If the child could speak in multisyllable utterances, note how many syllables they could say in one breath group and if they appear to be running out of breath by the end of their sentence or taking a breath in linguistically inappropriate places.   Normative Data on Maximum Phonation Duration (MPD) and Maximum Exhalation Duration (MED) Based on 20 males and 20 females per age group (Carlock et al., 2019; Potter, 2004). Age in Years

MPD Mean (SD) in Seconds

MED Mean (SD) in Seconds

3–4

3.45 (1.23)

6.08 (2.61)

5–7

11.65 (4.09)

11.13 (6.00)

8–9

14.23 (4.96)

13.72 (6.18)

10–12

15.77 (6.02)

17.55 (7.75)

continues

102   Here’s How to Treat Childhood Apraxia of Speech

Appendix 2–D.  continued

Articulation-Diadochokinetic (DDK) Task

DDK

Trial 1

Trial 2

Trial 3

Highest DDK Rate of the Three Trials

/pʌ/

_____ syllables/

_____ syllables/

_____ syllables/

= ___ syll/sec

_____ seconds

_____ seconds

_____ seconds

= ___ syll/sec

= ___ syll/sec

= ___ syll/sec

_____ syllables/

_____ syllables/

_____ syllables/

_____ seconds

_____ seconds

_____ seconds

= ___ syll/sec

= ___ syll/sec

= ___ syll/sec

_____ syllables/

_____ syllables/

_____ syllables/

_____ seconds

_____ seconds

_____ seconds

= ___ syll/sec

= ___ syll/sec

= ___ syll/sec

_____ syllables/

_____ syllables/

_____ syllables/

_____ seconds

_____ seconds

_____ seconds

= ___ syll/sec

= ___ syll/sec

= ___ syll/sec

/tʌ/

/kʌ/

/pʌtʌkʌ/

= ___ syll/sec

= ___ syll/sec

= ___ syll/sec

DDK comparative data in syllables/second for ages 2–15 years (Kent et al., 2021) These data represent a compilation of multiple studies of children without speech disorders. The ranges represent the lowest mean DDK rate to the highest mean DDK rate reported in these studies. (Outliers were removed from averages and ranges.)

a

Age in Years

/pʌ/ Mean (range)

/tʌ/ Mean (range)

/kʌ/ Mean (range)

/pʌtʌkʌ/ Mean (range)

2–3a

3.86 (3.46–4.74)

3.83 (3.38–4.56)

3.56 (3.36–3.75)

3.41 (2.82–4.23)

4–5

4.21 (3.62–4.92)

4.35 (3.54–4.82)

3.89 (3.00–4.76)

3.70 (2.86–4.47)

6–7

4.45 (3.93–5.56)

4.46 (3.42–5.88)

4.04 (3.33–4.74)

3.86 (2.91–4.74)

8–9

4.78 (4.54–5.88)

4.7 (4.30–5.88)

4.26 (4.12–4.49)

4.32 (3.85–5.19)

10–11

5.1 (4.63–5.56)

5.03 (4.66–5.56)

4.62 (4.50–5.00)

4.92 (4.22–5.46)

12–15

5.9 (4.76–6.06)

5.25 (4.46–6.06)

4.91 (4.39–5.40)

5.55 (4.35–6.66)

Although data are available for young children, it is not always possible to elicit the productions in a reliable and valid manner.

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   103

DDK observations:  In addition to comparing the child’s DDK rates to the norms above, note observations on rhythmicity, articulatory accuracy, voicing errors, sequencing errors, addition of a segment, deletion of a segment, consistency of errors, and ability to complete task. You can also compare ease of producing AMRs to the SMR task.   Summary of observations of resonance, phonation, respiratory support, and articulation:     Examination for Nonverbal Oral Apraxia (NVOA): Give verbal directions, then model if necessary. 0 = imitates immediately 1 = mild groping; or delayed but successful 2 = groping or sequential efforts (up to four tries), then success 3 = could not achieve imitation even though there is purposeful effort 4 = child does not/cannot attempt to do the task Blow out a candle

Smile

Puff out your cheeks

Smack your lips together

Clear your throat

Bite your lower lip

Score Sum NVOA Score ____________ (0–24 possible) Nonspeech Movement Sequencing (NSMS): Give verbal directions, then model if necessary (same scoring as above) Smile, Blow, Smile

Smack your lips together, then clear your throat

Sip through a straw, then bite your lower lip

Open your mouth wide, then lick the back of your top teeth

Score continues

104   Here’s How to Treat Childhood Apraxia of Speech

Appendix 2–D.  continued

Sum NSMS Score ____________ (0–16 possible) Sum PRAXIS Score ____________ (0–40 possible) For comparison to children without a speech sound disorder, see the table below to note if the child fell within the normal range. NVOA Average Scores With Standard Deviations and Ranges of Children With Typical Speech Development (GFTA-3 standard score of over 75) Age/Sample

Boys

Girls

6- to 7-year-olds (boys n = 35; girls n = 30)

4.3 (3.6) Normal range 0–10

2.5 (1.96) Normal range 0–6

8- to 9-year-olds (boys n = 50; girls n = 36)

2.3 (2.5) Normal range 0–6

1.9 (2.5) Normal range 0–6

10- to 12-year-olds (boys n = 51; girls n = 59)

1 (1.3) Normal range 0–3

1 (1.3) Normal range 0–3

Summary statement for NVOA:  include if the child’s performance fell within the normal range or not and diagnostic impressions on the child’s performance. 

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   105

APPENDIX 2–E

Dynamic Multisyllabic Word Repetition Probe (Skinder-Meredith & Fish, 2022)

Articulatory accuracy + if correct

Target Word

Transcribe or mark sounds that were incorrect, added, or omitted, if incorrect

Coarticulation + good smooth coarticulation − poor coarticulation − syllable segmentation

Lexical stress accuracy + correct − incorrect

If incorrect, is there improvement with backward chaining or other cuing methods? Y/N If so, note the method that was helpful.

Three-Syllable Words vacation /ve.ˈkeɪ.ʃən/ medicine /ˈmɛ.də.sɪn/ accident /ˈæk.sə.dənt/ gigantic /dʒaɪ.ˈɡæn.tɪk/ beautiful /ˈbju.ɾɪ.fəl/ character /ˈkæ.rə.ktɚ/ computer /kəmˈpju.ɾɚ/ magnified /ˈmæɡ.nə.faɪd/ subtraction /səb.ˈtræk.ʃən/ principal /ˈprɪn.sə.pəl/ continues

106   Here’s How to Treat Childhood Apraxia of Speech

Appendix 2–E.  continued

Articulatory accuracy

Coarticulation

+ if correct

Target Word

Transcribe or mark sounds that were incorrect, added, or omitted, if incorrect

+ good smooth coarticulation − poor coarticulation − syllable segmentation

Four-Syllable Words avocado /ɑ.və.ˈkɑ.doʊ/ macaroni /mæ.kə.ˈroʊ.ni/ television /ˈte.lə.vɪ.ʒən/ embarrassment /ɪm.ˈbæ.rəs.mənt/ calculator /ˈkæl.kjə.leɪ.ɾɚ/ celebration /sɛ.lɪ.ˈbrei.ʃən/ experiment /ɛk.ˈspɛ.rɪ.mənt/ impossible /ɪm.ˈpɑ.sə.bl̩/ punctuation /pʌŋk.tʃu.ˈeɪ.ʃən/ dictionary /ˈdɪk.ʃə.ne.ri/ combination /kɑm.bɪ.ˈneɪ.ʃən/

Lexical stress accuracy + correct − incorrect

If incorrect, is there improvement with backward chaining or other cuing methods? Y/N If so, note the method that was helpful.

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   107

Articulatory accuracy

Coarticulation

+ if correct

Target Word

Transcribe or mark sounds that were incorrect, added, or omitted, if incorrect

+ good smooth coarticulation − poor coarticulation − syllable segmentation

Five-Syllable Words congratulations /kən.ˌɡræ.t͡ʃəˈleɪ. ʃənz/ enthusiasm /ɛn.ˈθu.zɪ.jæ. zəm/ evaporation /ɪ.væ.pə.ˈreɪ.ʃən n/ intimidating /ɪn.ˈtɪ.mə.deɪ.ɾɪŋ/ unbelievable /ʌn.bə.ˈliː.və.bl̩/ photosynthesis /foʊ.ɾoʊ.ˈsɪn. θə.sɪs/ electricity /ɪ.lek.ˈtrɪ.sə.ɾi/ imagination /ɪ.mæ.dʒɪ.ˈneɪ. ʃən/ hippopotamus /hɪ.pə.ˈpɑ.ɾə.məs/ pediatrician /pi.di.jə.ˈtrɪ.ʃən/

Lexical stress accuracy + correct − incorrect

If incorrect, is there improvement with backward chaining or other cuing methods? Y/N If so, note the method that was helpful.

108   Here’s How to Treat Childhood Apraxia of Speech

APPENDIX 2–F

Sentential Stress and Intonation Probe (Adapted from Skinder et al., 1999) Directions: I am going to say a sentence. I want you to repeat the sentence exactly like I said it. (Stress italicized words. Use appropriate statement versus question intonation, and add tone of voice variations when appropriate, e.g., excitement for “We won the game!” or displeasure for “Go away!”) • Intonation Contour:  Mark + when the child matches the intonation contour and − when they do not. • Primary Stress:  Mark + when the child matches the stressed word(s) and − when they do not. • WSD:  Mark − if weak syllable deletion occurred and + if it did not.

Intonation Contour

Primary Stress

Omission Of Unstressed Words Or Syllables

 /10

 /10

 /10

1. Have you seen my cat? 2.  We won the game! 3.  This is so boring. 4.  I wanna go home. 5.  Is it time to go? 6.  Look at me. 7.  Please stop doing that. 8. Do you like pizza? 9.  Go away! 10. I like you. TOTAL TOTAL:    /30 =   %

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   109

APPENDIX 2–G

Phonetic Transcription Phonetic Symbols for American English Consonants, Vowels, and Diphthongs Consonants Phonetic Symbol

Sample Word

/p/

pot

/b/

bike

/t/

toe

/d/

dough

/ɾ/ flap/tapa

butter /bʌɾɚ/

/k/

cup

/g/

game

/ʔ/ glottal stopb

mitten [mɪʔn̩]

/m/

me

/n/

new

/ŋ/

ring

/w/

wait

/j/

you

/f/

fine

/v/

van

/θ/

thing

/ð/

that

/s/

sing

/z/

zoo

/ʃ/

shoe

/ʒ/

rouge

/h/

him continues

110   Here’s How to Treat Childhood Apraxia of Speech

Appendix 2–G.  continued

Consonants Phonetic Symbol

Sample Word

/tʃ/

chair

/dʒ/

jump

/l/

lake

/r/

run

a

The flap/tap is an allophone of /t/ and /d/ typically used for intervocalic alveolar stops when the second syllable is not stressed.

b

The glottal stop is dialectal and may occur when a /t/ or /d/ is unreleased and precedes a syllabic /n/ and occasionally syllabic /l/. Glottal stop substitutions can also occur as an error and should not be confused with omissions.

Pure Vowels Phonetic Symbol

Sample Word

/i/

team

/ɪ/

fit

/e/

pain

/ɛ/

pet

/æ/

hat

/u/

new

/ʊ/

push

/o/

coat

/ɔ/

ball

/ɑ/

hot

/ʌ/

fun

/ə/

again

/ɝ/

perfect

/ɚ/

super

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   111

Diphthongs Phonetic Symbol

Sample Word

/aɪ/

high

/aʊ/

out

/ɔɪ/

boy

When evaluating a child with an articulation disorder, it may be sufficient for the SLP to mark the substitution or distortion errors on the assessment form; however, when evaluating a child with suspected CAS, it is imperative for the SLP to be able to accurately transcribe the child’s productions narrowly. The nature of the speech characteristics, such as vowel distortions, lengthening or shortening of phonemes, syllable stress errors, and gaps between syllables, make it essential for the SLP to accurately transcribe the child’s speech using narrow transcription. An SLP completing a motor speech evaluation should be able to do the following: • identify the phonotactic structure of words • accurately transcribe speech phonetically • recognize and transcribe vowel errors, including distortions • use diacritical markers to describe nuances of the child’s speech • recognize gaps between syllables/words • recognize glottal stops • calculate the percentage of consonants and vowels correct Each of these transcription skills is described below.

continued

112   Here’s How to Treat Childhood Apraxia of Speech

Appendix 2–G.  continued

Identification of the Phonotactic Structure of Words and Phonetic Transcription When identifying the phonotactic structure of words, each consonant and vowel should be identified, along with the syllable breaks and stress assignment. The SLP should know what the correct phonotactic structure should be for the target word or phrase and be able to compare this to the child’s actual production of that target. Following are examples of phonotactic structures and phonetic transcriptions of accurately produced English words, including syllable breaks (identified with “ . ” between syllables) and stress assignment (identified with “ ‘ ” before the stressed syllable). Some words were left undone to practice. Answers can be viewed on the Online Book Companion.

Target Word

Phonotactic Structure

Phonetic Transcription

Brought

CCVC

/brɔt/

CVCC

/ʃɑpt/

‘CV.CV

/’bʌ.ni/

CCV.CVCCC

/prə. ˈnaʊnst/

CVC.CVCC

/ˈmɪl.yənz/

CVC. ‘CCV.CVC

/kən.’fju.zɪŋ/

V.CVC.CV.’V.CVC

/ɪ.væk.ju.ˈe.ʃən/ or /ɪ.væk.ju.ˈe.ʃn̩/

VCCVCC

/ʌn.bʌ.ʔn̩/

Touch Shopped Judged Bunny Machine Pronounced Subscribes Millions Earthquakes Confusing Beautiful Evacuation Incredible Unbutton Forgotten

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   113

Diacritical Marks When using narrow transcription, there are numerous diacritical marks that can be used to describe nuances in the child’s speech that the phonetic transcription alone would not be able to describe. Only a few diacritical marks are listed below. Please refer to the Online Book Companion to hear audio files of these practice words to help better understand the meaning and use of these diacritical marks.

Symbol Used

Phonetic Transcription

Syllable stress marker

ˈ

bunny [ˈbʌ.ni]

Syllabic consonants (e.g., /n, l, m/)

̩

Purple [ ˈpɝ.pl̩]

Glottal stop

ʔ

Mitten [mɪ.ʔn̩]

Aspiration

h

Top [thɑp]

Dentalization

◌̪

Top [t̪ɑp]

Lateralization

ˡ

Bus [bʌˡs]

Lengthening

ː

Top [tɑːp]

Nasalized

◌̃

Tap [tɑ̃p]

Diacritical Marks

Syllable gap

..(short gap) …(longer gap)

Baby [ˈbe..bi] [ˈbe...bi]

No audible release

◌̚

Tap [tɑp ]̚

Extra short

◌̆

Bed [bĕd]

More rounded

◌̹

Saw [sɔ̹ ]

Less rounded

◌̜

Saw [sɔ̜ ]

Creaky voice

◌̰

Box [b̰ɑ̰ks]

Breathy voice

◌̤

Box [b̤ɑ̤ks]

Following are examples of productions of target words phonetically transcribed without diacritical marks and with diacritical marks. When you go to the Online Book Companion, you can listen to how each word would be produced without and with diacritical markers. The differences are meaningful and offer important information about how a child actually produces the target words. continues

114   Here’s How to Treat Childhood Apraxia of Speech

Appendix 2–G.  continued

Target Word

Phonetic Transcription Without Diacritical Marks

Target Word

Phonetic Transcription With Diacritical Marks

Brought

[bap]

Brought

[bɑp ̚]

Touch

[dʌ]

Touch

[d̪ ʌ]

Bunny

[bʌ.ni]

Bunny

[ˈbʌ...ˈn̪ ːi]

Machine

[din]

Machine

[dı̃:n]

Confusing

[du.du]

Confusing

[ˈd̪ u.d̪ u]

Beautiful

[bu.bo]

Beautiful

[ˈbu...ˈbo]

Calculation of percentage of consonants and vowels correct To calculate the percentage of consonants correct (PCC) or percentage of vowels correct (PVC), the following equation is used: PCC-R = Number of correct consonants (excluding distortions) ÷ Total number of consonants × 100. PVC-R = Number of correct vowels (excluding rhotics) ÷ Total number of vowels × 100. To calculate the percentage of phonemes correct (PPC), the following equation is used: PPC-R = Number of correct phonemes (excluding rhotic vowels and distorted consonants) ÷ Total number of phonemes × 100. For practice calculating Percentage Consonants and Vowels Correct, please go to the Online Book Companion and try the practice activities.

2.  Assessment and Differential Diagnosis of Childhood Apraxia of Speech   115

Percentage of Phonemes Correct

Number of Phonemes in Target Word

Number of Phonemes Produced Correctly by Child

Target Word

Transcription

C

V

C

V

Brought

[bɑp ̚]

3

1

1

0

Touch

[d̪ ʌ]

2

1

Bunny

[ˈbʌ...ˈn̪ ːi]

2

2

2

2

Machine

[dı̃:n]

3

2

Confusing

[ˈd̪ u.d̪ u]

6

3

0

1

Beautiful

[ˈbu...ˈbo]

5

3

21

11 % correct consonants

% correct vowels

TOTALS

PERCENTAGES

When determining the percentage of phonemes correct, minor distortions or incorrect articulatory placements (e.g., dentalization of /n/ in “bunny;” nasalization of the /i/ in “machine”) are counted as correct. The use of diacritics, however, is still important, because it provides important nuanced information about the way the child produces utterances (e.g., equal stress, syllable segmentation, nasalization).

CHAPTER

3

Fundamentals of Treatment for Childhood Apraxia of Speech

W

hen providing treatment for children with childhood apraxia of speech (CAS), there are several underlying principles to keep in mind. Although each child’s profile will be unique, certain principles will remain consistent in treatment. These include the following: • understanding the principles of motor learning that will guide treatment decisions • providing opportunities for repetitive practice • addressing phoneme sequencing and coarticulation • selecting appropriate target utterances for treatment • incorporating multisensory cueing • providing sufficient intensity of treatment

Principles of Motor Learning and Their Application to Treatment of CAS This section describes the principles of motor learning (PML) that guide treatment decisions when working with children with CAS. These principles correspond to the substantial amount of research on motor learning principles from the field of motor control and learning. Maas et al. (2008) offer a comprehensive discussion of the PML and their relationship to speech motor learning in adults and children. Research regarding PML in CAS treatment is somewhat limited; however, there have been some studies over the past several years that have helped guide speech-language pathologists (SLPs) in their application of PML to treatment of children with CAS. In CAS treatment, children first need to acquire a skill, then work on retention and generalization of the skill. The organization of the sessions will look different depending on whether we

117

118   Here’s How to Treat Childhood Apraxia of Speech

are trying to support initial acquisition of a skill or help the child retain and generalize the skill. These principles, described by Schmidt and Lee (2005), suggest optimal conditions of practice that support the initial acquisition of motor skills, as well as retention (maintenance) and transfer (generalization) of these skills. Table 3–1 lists the PML that have the greatest impact on our treatment decisions. Each of these principles is discussed in greater detail in the rest of this chapter.

Pre-Practice During pre-practice, the clinician draws the child’s attention to aspects of the target utterances that require change. Several teaching and cueing strategies are incorporated into pre-practice,

Table 3–1.  Principles of Motor Learning Guiding Treatment Decisions in Children With CAS Principles of Motor Learning Related to Conditions of Practice

Descriptions

Pre-practice

Preparation for learning — providing cues and strategies to set the stage for learning to occur

Distribution of practice • Massed • Distributed

Length and frequency of sessions

Practice amount/number of trials • High # of trials • Low # of trials

Number of practice trials provided during a given session

Schedule of practice • Blocked • Random

Practicing one target skill repeatedly (blocked) or several target utterances in random order (random)

Variability of practice • Constant • Variable

Providing opportunities to vary the motor plan (e.g., rate, prosody, pitch)

Principles of Motor Learning Related to Conditions of Practice

Descriptions

Type of feedback • Knowledge of performance • Knowledge of results

Providing specific feedback or general feedback

Frequency of feedback • High frequency • Low frequency

How frequently the feedback is provided

Timing of feedback • Immediate • Delayed

Whether the feedback is provided immediately after the child’s productions or after a delay

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   119

such as shaping, modeling, phoneme placement cues, probing for facilitating contexts, focused stimulation, or work on discrimination of correct and incorrect productions. During pre-practice, the clinician introduces relevant information about the target utterances and provides opportunities for the child to accurately achieve sensorimotor plans for those targets. This gives the child the sensory experience (tactile, kinesthetic, proprioceptive, and auditory sensations) of achieving several correct productions of the desired response prior to moving on to the practice phase. In essence, pre-practice sets the stage for the child to be successful during the practice portion of the session. During the pre-practice portion, the clinician provides frequent and specific feedback about what the child did well and what the child needs to do differently. The clinician facilitates the child’s motivation and focused attention. Motivation is enhanced when the clinician develops a rapport with the child and provides strategies and opportunities for the child to be successful in communicative attempts. Fun and engaging activities (that do not take too much time away from practice) also will make the learning more enjoyable and more motivating. To facilitate focused attention, the clinician provides cues that bring the child’s attention to the clinician’s face, so the child can see what is expected in terms of movement of the oral-facial structures. When a child is reluctant to look at the clinician’s face, video modeling can be used as an alternative. The initial use of slower rate and tactile cues also helps the child focus attention internally on how the movement should feel through development of greater proprioception. Focused attention also helps the child develop an understanding of why they are there and what they are working on — movement. The words you choose when speaking to the child help bring the child’s attention to movement (e.g., “I like the way you moved your tongue tip up to make the /t/ sound.” “Your mouth moved just like my mouth!”).

Distribution of Practice — Massed/Distributed Distribution of practice refers to the frequency and duration of treatment sessions. Schmidt and Lee (2005) suggest that individuals achieve better performance using a massed practice schedule of more frequent sessions over a shorter period (e.g., four sessions per week for 8 weeks) than a distributed practice schedule of less frequent sessions over a longer period (e.g., twice-weekly sessions for 16 weeks). Research by Thomas et al. (2014), Murray et al. (2012), and Namasivayam et al. (2015) confirmed this recommendation, as children in their studies receiving massed practice treatment had better outcomes than those with distributed practice schedules. A study by Allen (2013) found that children with phonological impairments (not CAS) who received frequent sessions for a shorter time frame (i.e., three sessions per week for 8 weeks) demonstrated better performance than those who received less frequent intervention over a longer time frame (i.e., one session per week for 24 weeks).

Practice Amount — High/Low Higher amounts of practice (number of practice trials within a given session) should lead to better treatment outcomes. Edeal and Gildersleeve-Neumann (2011) provided validation of the importance of frequent production of treatment targets in children with CAS. Their research found that when targets were practiced with higher frequency (100+ productions of each target within a session), there was faster improvement and greater generalization to untrained targets than when targets were practiced at a lower frequency (30–40 productions of each target within a session). In a more recent study by Maas et al. (2019), most of the subjects

120   Here’s How to Treat Childhood Apraxia of Speech

demonstrated better motor learning with higher amounts of practice of each target utterance (e.g., ≅14 practice opportunities versus ≅7 practice opportunities of each target utterance per session). These findings are important because they remind clinicians that it is critical to use treatment time efficiently, so the child has more practice opportunities.

Schedule of Practice — Blocked/Random In blocked practice, the child would practice a specific target utterance for a specified number of trials before moving on to the next stimulus item. In random practice, the child would practice items in a random order. Maas et al. (2008) suggest that blocked practice may be more effective in promoting early learning of targets during the acquisition stage, whereas random practice facilitates retention and transfer of sensorimotor speech plans. Maas and Farinella (2012) compared random versus blocked practice treatment schedules in children with CAS and found mixed results, with some subjects demonstrating better results with blocked and some showing an advantage with random practice schedules. It is likely that the child’s response to blocked practice or random practice schedules is dependent on where the child was in the acquisition of the particular motor skill being addressed. Strand (2020) suggests using a modified block practice schedule “that begins with blocked practice and moves to shorter blocks and finally random practice” (p. 41). In a modified block schedule, a child practices multiple productions of one stimulus item in a block (“Hi mommy”) before moving on to the next block with a different stimulus item (“Go home”). Within each block, the child works toward increasing accuracy of production with greater variability (e.g., loud, quiet, fast, slow, varied intonation patterns) and reduced cueing. In the early stages of acquisition of a new sensorimotor plan, blocked practice of the target utterance is recommended. After the child is able to produce the target utterance more reliably without intensive cueing and with normal prosody, the utterance could be practiced along with other target utterances in a more randomized order. Consider a child who is working on eight targets: “Hi mom,” “Oh wow!” “Bye daddy,” “Go home,” “I do,” “nigh nigh baby,” “shhh,” and “all done.” The clinician may set up several activities for the session. During the first activity, the child can produce “Hi mom” each time a toy character gets off the school bus and greets the “mommy” figure until the child has achieved 30+ practice trials of “Hi mom.” The “mommy” figure can then tell the toy characters that she has a surprise in the kitchen to elicit “Oh wow” for 20+ trials before moving on to the second activity to work on “Bye daddy” and “go home.” Because of the child’s earlier success and stability with “I do” (from a prior session) and “Oh wow!” the clinician will practice these two utterances in a random practice mode, shifting between the two targets in random order. The final two activities would elicit three new targets, “nigh nigh baby,” “shhh,” and “all done,” along with two targets practiced earlier, “go home” and “Hi mom,” each practiced in a blocked schedule. A sample blocked and random practice schedule for a child with severe CAS is shown in Figure 3–1. In reality, the clinician will be making decisions about using a blocked or random practice schedule based on the child’s responses in the moment. The child may be producing target utterances in random order, but if the child begins to struggle with a specific target, the work on that target would shift to blocked practice before it is rotated back into the random practice schedule. For a child with severe CAS, a small number of stimulus items (perhaps five or six items) would be practiced during a treatment session using a blocked schedule. When the child’s production of a stimulus item is stable in a blocked schedule, that stimulus item can be rotated into a set of stimuli to practice in a random schedule.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   121

Figure 3–1.  Sample blocked and random practice schedule. (BP, blocked practice; RP, random practice.)

The example in Box 3–1 provides a case study of a child who is struggling with CVC shapes. You will see the clinician shift from a blocked to a random practice schedule as the child’s skills improve. In phonological intervention, working on final consonant deletion is a common goal, and it often is addressed by choosing stimuli with a variety of final consonants (e.g., hat, mom, moon, cup, back). For a child with CAS, however, final consonants may need to be addressed more methodically, with a focus on sensorimotor planning, first choosing a final consonant for which the child is stimulable, perhaps a bilabial continuent, such as Box 3–1.  Case Illustration of Blocked and Random Practice Schedule Kamal is a 4-and-a-half-year-old boy with moderate-to-severe CAS. It was difficult for him to work on mixed targets within the same session, as he would overgeneralize from earlier productions. For example, when working on closing syllables with a final consonant, Kamal achieved early success with final /m/. When attempting to vary the final consonant by introducing a different target, such as final /f/ or /t/, Kamal demonstrated overgeneralization of the /m/ and would insert /m/ for all final consonants. Eventually, final /t/ was introduced in a blocked practice condition of practicing all final /m/ targets during one activity and all final /t/ targets in a separate activity. Over time, other targets with varied place, manner, and voicing features were added to expand Kamal’s coarticulatory flexibility. Eventually he was able to demonstrate a high level of accuracy when we shifted to a random practice condition where different targets were practiced in random order (e.g., go home, off, go out, hi mom, enough, hey wait, go home, enough, hi mom, off, go out, hey wait). Table 3–2 illustrates the changes in practice schedule over time for Kamal’s final consonant productions.

122   Here’s How to Treat Childhood Apraxia of Speech

Table 3–2.  Sample Practice Schedule Illustrating Movement From Blocked to Random Practice Week 1

Week 2

Week 4

Week 6

Blocked practice

Blocked practice

Random practice

Random practice

Activity 1:  Final /m/

Activity 1:  Final /m/

Activity 2:  Final /m/

Activity 2:  Final /t/

Activity 1:  Final /m/ and final /t/

Activity 1:  Final /m/, /t/, and /f/

Blocked practice

Activity 2:  Final /m/, /t/, and /f/

Activity 2:  Final /f/

/m/, before moving on to other consonant phonemes with variations in place and manner of production.

Variability of Practice — Constant/Variable Practice variability relates to practicing target stimuli in either a relatively constant manner/ context (constant practice) or in varied manners/contexts (variable practice). A clinician can vary the manner of production of a target by changing • rate of production • loudness • pitch • tone of voice • intonation Contextual variability may include the following: • using varied phonetic contexts to achieve variability in movement patterns • varying sentential stress • practicing targets in different settings • practicing with a less familiar communicative partner • shifting from single-word productions to phrase-/sentence-level productions When first learning a challenging sensorimotor plan, a child benefits from practicing targets at a relatively constant rate and with relatively consistent vocal parameters (loudness, pitch, vocal quality, intonation, stress). After the child is able to produce the desired sensorimotor plan, practice should become more variable. Children can practice producing the targets using variable rates of production (normal or slow rate), volume (whispered, normal, and louder), pitch (like papa bear, mama bear, baby bear), vocal quality/tone of voice (using an angry, sad, happy, tired voice), intonation patterns (declarative statement versus yes/no question), or stress (placing stress on different words within the phrase/sentence). The clinician can introduce variability in practice by having the child produce target utterances in different settings (in treatment room, hallway, classroom, playground) and with different communicative partners (clinician, parents, siblings, familiar and less familiar peers and adults). Altering the manner and context of the practice will lead to better maintenance and generalization of skills.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   123

Types of Feedback — Intrinsic/Extrinsic, Knowledge of Results/Knowledge of Performance Schmidt and Lee (2005) divide feedback into two basic types: inherent feedback and augmented feedback. Inherent feedback, also known as intrinsic feedback, is derived naturally from the sensory information received from the movement itself. In the case of speech, intrinsic feedback for a learner would include the tactile, kinesthetic, and proprioceptive input received through the skin, muscles, and joints, as well as auditory feedback received from listening to the production and examining if the production matched the intended outcome. Because children with CAS may have a reduced ability to detect the somatosensory information received through tactile and proprioceptive input during the process of speaking, they tend to rely on auditory feedback and possibly faulty error detection of their speech. Thus, it is imperative that the clinician provides the child with augmented feedback, also termed extrinsic feedback, which is information provided by an outside source. Extrinsic feedback can be provided either as knowledge of performance (KP) or knowledge of results (KR). Schmidt and Lee describe KP as feedback about the movement itself (“Your tongue poked through your teeth that time. Try again with your tongue behind your teeth.” “Nice job rounding your lips for that one!”). KR refers to knowledge about the accuracy of the movement, that is, whether the production was correct or incorrect (“That was correct.” or “Not quite. Try it again.”). KP feedback supports early attainment and acquisition of a sensorimotor plan; KR supports generalization and retention of the sensorimotor plan. It is key that the information provided as KP is clear and specific to the features of movement that need to be changed. When the learner has shown the capacity to produce the sensorimotor plan with a fairly high level of accuracy with KP, the clinician would shift the feedback to KR. Schmidt and Lee indicate that performance and generalization outcomes actually can be hindered if children become reliant on KP feedback. Clinicians often fall into a pattern of providing praise (e.g., Very good!), almost as a knee-jerk reaction, even when the child’s productions do not meet the expected goal. We often want to provide positive reinforcement but may be reinforcing incorrect productions. For example, the utterance is “go home,” and the child said, “go ho.” It would be better to say, “You used good circle lips but forgot your humming lips at the end,” than to say, “Good job! Try again with your ‘mmmm’ sound at the end.” The difference is subtle but less confusing for the child. By providing specific KP feedback, we can provide reinforcement for what the child did well, while providing constructive feedback. Examples of KP feedback are shown in Table 3–3. Table 3–3.  Examples of Specific Feedback (Knowledge of Performance) in Treatment Target Utterance

Child’s Response

Hi mom.

/hɑ mam/

“I like how you used your breath for /hɑ/. This time, be sure to finish with ‘smile lips’ when you say, hi - Ha-eeee.”

Hi mom.

/haɪ mam/

“You used your smile lips when you said hi. Great job!”

banana

/næ.nə/

“That word has three syllables. Try again. We’ll tap it out together.”

banana

/bə.næ.nə/

“Nice job! You got all your sounds that time.”

Therapist’s Response

124   Here’s How to Treat Childhood Apraxia of Speech

Frequency of Feedback — High Frequency/Low Frequency A second consideration with regard to feedback is the frequency with which the feedback is delivered, with feedback being more frequent during earlier stages of acquisition and decreasing gradually as the child improves. Maas et al. (2012) examined if reducing frequency of feedback would enhance motor learning in children with CAS; however, their findings were inconclusive. The authors suggest that a child’s age or the severity of the child’s speech challenges may factor into how well they are able to benefit from a reduced schedule of feedback during production activities. Teachers and therapists tend to want to provide positive reinforcement frequently to keep children motivated and feeling good about their work; however, we do not want children to become feedback dependent, so gradual reduction in feedback is recommended.

Timing of Feedback — Immediate/Delayed Schmidt and Lee (2005) provide evidence related to optimal timing of feedback during motor learning. They warn against providing feedback too soon after the performance of the movement. When feedback is provided instantaneously upon completion of a target, the child does not have adequate time to reflect on the performance and compare the production to the desired output, which may hinder both acquisition and retention of the sensorimotor plan. Even a delay of 2 or 3 seconds before providing the child with feedback can support acquisition and retention of the sensorimotor plan. In summary, SLPs can refine their treatment for children with sensorimotor speech challenges. Children’s speech outcomes can be enhanced when clinicians understand the PML and consider these principles when making treatment decisions. Clinical judgment, of course, is required to analyze how individual students are responding to specific conditions of practice and conditions of feedback, and to vary the practice conditions as needed to meet the needs of specific clients. Table 3–4 provides a summary chart of the application of motor learning Table 3–4.  Summary of Principles of Motor Learning in Acquisition and Retention Phases of Treatment

Facilitating Acquisition of Skills

Motor Learning Principles

Facilitating Retention And Transfer of Skills

CONDITIONS OF PRACTICE High levels of cueing and feedback

Pre-practice

Not applicable

High number of trials per session

Number of trials

High number of trials per session

Blocked practice

Schedule of practice

Random practice

Constant practice

Variability of practice

Variable practice

CONDITIONS OF FEEDBACK High frequency

Frequency of feedback

Gradual reduction in frequency

Knowledge of performance

Type of feedback

Knowledge of results

Immediate feedback

Timing of feedback

Delayed feedback and summary feedback

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   125

principles to the current best practices for children with sensorimotor speech disorders. Further research will continue to shed light on how these principles can best be applied when working with children with CAS.

Repetitive Practice In the previous section, the importance of incorporating high practice amounts to facilitate motor learning was discussed. One challenge facing clinicians is finding ways to keep children motivated, interested, and engaged when working on many of the same skills repeatedly. In this section, we discuss how to set up an environment to help children sustain attention, persistence, and willingness to engage in repetitive practice activities in the face of frustrations that often exist for individuals who struggle to communicate verbally.

Tips for Creating a Learning Environment That Promotes Repetitive Practice Following are tips for creating a learning environment that will encourage a practice mindset for children: • Provide a pleasant learning environment without unnecessary visual and auditory distractions. • Provide seating that facilitates postural stability for the child. • Sit facing the child and at the child’s eye level to encourage the child to look at your face. • For infection control, consider a clear mask resistant to fogging or a modified shield that fills in the gap between the shield and the face, such as the Bend Shape mask or the Badger Shield, so the child can still see your face.

• For children who struggle to attend to the clinician’s face, consider using video modeling (described in greater detail later in this chapter). • Reduce the number of materials within the child’s reach to help reduce distraction. • Consider the child’s age, attention span, frustration tolerance, persistence, and interests when planning intervention activities. • Choose activities that are quick and simple, yet motivating and reinforcing, to increase practice opportunities (e.g., craft projects may be fun but are too time consuming). • Have an efficient, organized manner for data collection (see Chapter 12). • Have a visual representation of how many reps they need to produce before moving on. (e.g., token tower, count down on the hand and end with a high five after five reps of good productions, 10 × 10 grid to fill with stickers or stamps)

Repetitive Practice Activities to Support Varied Interests Another important consideration in repetitive practice is finding activities that spark the child’s interest. Children vary in what they find interesting and motivating. Making the treatment activities enjoyable for children will impact their willingness to put forth the effort necessary

126   Here’s How to Treat Childhood Apraxia of Speech

to achieve gains in treatment. Talk with the child and the family to find out what types of activities the client enjoys, ask colleagues about activities they have used successfully in treatment to elicit high numbers of responses within a session, and be creative. For instance, some children show their best work when they can be moving, while other children prefer quiet activities or the challenge of earning points. Table 3–5 describes several activities that elicit multiple repetitions of targets. The activities are simple and quick so children can spend most of their time working on speech, rather than using precious practice minutes setting up elaborate games and projects. Each of the activities is sorted based on the specific interests of the child.

Phoneme Sequencing, Syllable Shapes, and Coarticulation The ability to combine sounds fluidly and to make minor adjustments in articulatory placement based on surrounding phonemes is referred to as coarticulation. The American Speech-Language-Hearing Association (ASHA, 2007) describes challenges in the planning and programming of speech movements for smooth coarticulation as a core deficit for children with CAS. Thus, it is important to rethink our treatment goals and to rethink the way we talk to children about their goals and the work they are doing. Strand (2020) suggests that rather than thinking and talking about specific phonemes, we think and talk about speech movement sequences. Thinking in terms of movement sequences is essential for addressing coarticulation in CAS treatment. Following are things to consider when addressing phoneme sequencing and coarticulation in children with CAS.

Addressing Syllable Shape Complexity The term syllable shape refers to the ordering of consonant (C) and vowel (V) phonemes within a syllable. The words “me” and “shoe” have a syllable shape of CV, “school” and “trip” have a CCVC shape, and “splashed” and “streets” have a CCCVCC shape. Words with more than one syllable such as “mommy” and “happy” combine two CV syllables to form a CVCV shape, while “hotdog” and “goodnight” combine two CVC syllables to form a CVCCVC shape. Note that the phonemes, not the alphabetic letters used to spell the word, determine the syllable shape. It is useful to think of short phrases in terms of syllable shape. For instance, “Hi mom,” when produced without a pause between the words, could be considered to have a CVCVC shape and “Oh no” to have a VCV shape. Remember that helping children develop smooth, accurate, and consistent coarticulatory transitions within words and between words will be a primary focus of treatment. A child’s ability to produce increasingly more complex syllable shapes is a progressive skill. Table 3–6 illustrates a progression of syllable shape development, along with sample words and phrases that are representative of these syllable shapes. This progression should be viewed as a reference rather than an absolute progression, as you often will be choosing target utterances with a variety of syllable shapes even within the same intervention session. For example, a child may be working on CVCVCV targets (e.g., banana, hi daddy, we go now) while also working on single-syllable targets with simple syllable shapes when addressing inclusion of final consonants (e.g., up, in, hot) or production of more challenging phonemes (e.g., show, shoe, see).

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   127

Table 3–5.  Activities to Facilitate Repetitive Practice of Target Utterances Activities That Get Children Moving Bowling

Place blocks on the floor either in the positions of bowling pins or a few inches apart in a row. The child names the target pictures several times before placing each picture against a block. When each block has a picture, the child can roll a ball and knock over the blocks. After the pictures are knocked over, say the target word several times again. Variation: Use the target word in a carrier phrase such as “__________ fell down.” or “I knocked over a __________.“

Basketball

The child takes a shot at making a basket after saying the target word or phrase 10 times. The basket may be a small basketball hoop attached to a door or a large laundry basket on the floor or on a raised surface.

Picture hop

Pictures are placed in a row approximately 1 foot apart. The child names each picture several times as they hop from picture to picture. Variation: Each time the child hops onto a picture, have the child insert the word into a carrier phrase such as “I hopped on a __________.“

Treasure hunt

“Hide” the practice cards around the room and have the child use a flashlight to find the hidden cards. Once found, the child says the word five times. Variation: Each time a picture is found, use the word in a carrier phrase such as “I found a __________.” or “The __________ was hiding under/in/behind a __________.” Hint: To reduce the time it takes to search for the pictures, portions of the pictures should be visible, and the children may “peek” while the pictures are hidden.

Ball toss/roll

The child sits or stands several feet from the therapist. The child says the target word or phrase each time the ball is tossed or rolled back and forth.

Mailman

After naming each word several times, place the word card in an envelope to be delivered to a family member, stuffed toy or doll using a truck as the delivery vehicle. Name each picture again as it is delivered. Variation: Use a carrier phrase such as “You got a __________.” or “Here’s a __________.” when delivering the mail.

Beanbag throw

Name each picture and turn it upside down on the floor. Throw a beanbag onto a picture, turn it over, and name it several times.

Move and say

Pictures are separated into two decks: target picture deck and action deck. The action deck contains written instructions or a picture of an action the child will perform while producing the target utterance. The child picks one card from each deck and produces the target word while performing the action shown on the action card (e.g., the child says the target word “butterfly” while tapping his head; the child says the target word “bus” while hopping like a bunny).

Hop to it

A target picture or toy is placed on the floor or table. The child stands a good distance from the picture/toy and hops as many times as it takes to reach it. The target utterance is produced before each hop. The distance the child stands from the picture/toy can be varied, allowing the child to guess how many hops it will take to reach the picture/toy. continues

Table 3–5.  continued Activities for Pretend Play Go for a ride

Take dolls, toy characters, superheroes, or animals for a ride in a vehicle. Characters can be named (consider choosing names of familiar family, friends, classmates, neighbors). Multiple toys provide opportunities for repetitive practice of phrases (e.g., ____ on the bus; go in; open door). Hint: For children working on CV and CVCV, reduplicated shapes (e.g., cow, moo, neigh neigh, baba), farm animal names and noises can be appropriate targets, while zoo animals can be appropriate targets for CVCV variegated, CVCVC, and other complex syllable shapes (e.g., hippo, rhino, zebra, monkey, alligator, penguin).

Time to eat

Take those characters and animals to a restaurant or into the kitchen and give them something to eat. There will be plenty of opportunities to practice functional vocabulary and phrases/sentences (e.g., mommy eat apple; time to eat; I’m hungry; more cookies).

Doctor

Pretend these characters get sick or hurt. Again, so many opportunities exist to practice functional words and phrases (e.g., body parts; boo boo; sick; hurt; owie; I hurt my ___).

Take care of baby

Taking care of a doll provides opportunities to practice functional words and phrases related to bedtime routine, eating routines, and dressing routines. Activities to Show Your Creative Side

Block designs

After saying the target several times, the child earns a block with which to create a design.

Tall tower

After saying the target several times, the child earns a large block to create a very tall tower — knocking it over is the best part!

Dominoes

Tape two index cards with target words/pictures together at the edge so that you are able to stand them up in an inverted V or tent. Each time the child says the word correctly several times, place the card on the floor so it stands up. Each time a new card is completed, place it next to the last card so that the cards form a dominoes chain. At the end, knock them over and enjoy the chain reaction. Variation: Phrases can be created using the two target pictures that are taped together (e.g., “boy,” “toy” “The boy got a new toy toy.”). Note: Using words that form compound words is a nice way of linking the two words together (e.g., “cow,” “boy” “cowboy”)

Stickers

Divide a piece of paper into several boxes (one box for each target word/phrase). After saying each target several times, the child earns a sticker to place in each box.

Progressive drawing

Each time the child produces the target several times, the therapist draws “part” of a picture. Continue until the picture is complete. The child can try to guess what you are making as you go along.

Paper chain

Place a picture or write each practice word, phrase, or sentence on a 1-inch-wide strip of paper. After the child says the target several times, glue the paper ends together to create a circle. Thread each paper strip through the last and glue the ends until a paper chain is created. Variation: Each time a new word is added to the chain, use a carrier phrase “I put on a __________.” or “The ________ is attached to the ________.”

128

Table 3–5.  continued Earn it now, make it later

The child earns individual parts to an art project each time the target is produced several times. After all parts are collected, place them in a bag (along with the instructions) and send them home with the child to complete later.

Act it out

After reading a storybook, act out the story. In the repetitive line storybook, Mr. Gumpy’s Outing (Burningham, 1971), the child has opportunities to act out the story by placing animal characters in a boat and taking them for a ride before the boat finally tips over.

Sing out

Sing songs to reinforce the target utterances being addressed in therapy, whether they be familiar children’s songs or song lyrics you make up yourself. Activities for the Mathematical Mind

Large number die

Use blank dice (available from Super Duper Publications) and label them with numbers 5–10. The child says the target the number of times designated on the die.

Large number spinner

Make your own spinner with higher numbers. This can be done by applying blank stickers over the original numbers on the spinner with the new, higher numbers written on them. After spinning the spinner, the child produces the target the number of times indicated on the spinner.

100 (or 200 or 300 or . . . )

The child earns points for each correct production of the target. The numbers are added together. The child wins the game when the predetermined number is reached.

Double dice roll

Instead of one die, use two dice. Add up the numbers on the two dice and have the child produce the target that number of times. Miscellaneous Activities

Go Fish

Using two sets of pictures, play a game of Go Fish. The child asks you for pictures and then has to obtain pairs. This is a good activity for working on using the target words in phrases and sentences. Variation: Have the child use the carrier phrase “Do you have a __________.” or “I need a __________.” each time it is his turn. Also practice saying “Go fish” and “Yes, I have a __________.” and “No, I don’t have a __________.”

Memory

Place two sets of picture cards face down on the floor. Pick up and name two pictures at a time and try to find matching pictures. Continue until all matching pictures have been found. Variation: Each time a picture is turned over, use the carrier phrase “I got a __________.” If the two pictures turned over match, the phrase “I got 2 __________.” and “I got a match.” can be used; if not “No match” or “They do not match.” can be used.

Guess the picture

Place two or more pictures on the table and ask the child to name each picture several times. The pictures are then turned over and mixed up. The child chooses a picture to turn over, but before it is turned over, the child guesses the picture. Variation: For phrase-/sentence-level productions, the child can say, “I think the ________ is here.” “I think this one is a ________.” or “It’s a ________.”

continues

129

Table 3–5.  continued Make a puzzle

Find a colorful picture from a magazine or print a picture that would be of interest to the child and carefully remove it from the magazine, so it stays intact. Glue several target pictures to the back of the magazine picture. Cut around each picture into squares or curved shapes to separate each target picture. The child names each target picture several times and then turns them upside down. The pieces fit together to form a puzzle and reveal the colorful magazine picture. The number of puzzle pieces used will vary depending on the visualperceptual skills of each child.

Feely box

Place small objects in a box with a hole large enough for a child to insert a hand and feel around. Have pictures of each of the objects upside down on the table. The child turns over the pictures one-by-one and tries to locate the objects that match each picture by feeling around inside the box. Variation: The pictures are turned right side up on the table. The child chooses an object from inside the box and, without looking at it, tries to identify what it is from among the pictures available.

Production tracker

For a quick way to achieve 100 repetitions, create a transparent 10 × 10 grid in Word (to make 100 boxes) and overlay it on an image the child would find motivating (e.g., from a favorite TV show, a pet, a favorite place). Make an X or 3 in each square of the grid as the child practices their target stimuli. an

Board game

Make a board game using a manilla folder and a free downloadable game template. In each space of the game, provide a direction (e.g., Say phrase 10 times with your hands in the air and a loud voice, say phrase 15 times with a happy voice, say phrase 12 times as a question). The phrases can be on index cards in different colors to match the colors on the game board. This allows you to change out the phrases without changing the game board. Personalize the game by using graphics of things the child is interested in, like sports, a princess castle, or Mario Bros.

Applications specific for apraxia and articulation

There are many applications (apps) for articulation and specifically for CAS. These apps can be used during in-person sessions or during telepractice sessions by using the mirroring function on your tablet computer. Following are a few of these apps: Apraxia Picture Sound Cards (APSC Pro) — $179.99. Over 1,000 pictures ranging in complexity from CV and VC words to four-syllable words. Includes data collection and analytics. Card sets can be customized and saved and shared with caregivers. Apraxia Rainbow Bee — $26.99. Targets CV, VC level through three-syllable words and sentence-level productions. Data tracking available. Custom words can be added. Apraxia Farm — $29.99. Targets words with increasingly complex syllable structures of one to four syllables in length. Data tracking available. Custom words can be added. Bla Bla Bla — Free. For young children who are working to increase vocalization. This is a sound-reactive app. The child produces a sound, and the character’s mouth widens according to how loud the vocalization is. Boom Learning — Search the Boom Learning library for PROMPT Institute boom decks, which are stories that feature target utterances based on PROMPT’s Motor Speech Hierarchy. You can also use search words to find other boom decks specifically developed for children with CAS.

130

Table 3–5.  continued Applications specific for apraxia and articulation

Linguisystems Apraxia Sound Cards — $24.99. This is the online version of the Linguisystems Apraxia Sound Cards. The app contains 240 pictured items to practice words with increasingly complex syllable shapes in single words, phrases, and sentences. Speech Box for Speech Therapy — cost depends on usage. Hundreds of photos sorted by phoneme and category. Custom pictures can be added and new categories can be created and individualized (e.g., by syllable shape or specific child’s targets). Speech FlipBook — $9.99. The child hears and makes each sound individually and then blends them into CV, CVC, or CVCV real and nonsense words. You can limit the selections to real words only. Supports phonological awareness and phoneme production and sequencing. Speech Stickers — $14.99. The child practices C, V, VC, and CV sounds and syllables by imitating various models of the target stimuli that change in pitch and prosody. Speech Therapy for Apraxia — a set of four apps/$4.99 each. The stimuli for each set progress from simple CV syllables to more complex word shapes. An in-app purchase is required to use the progress tracking feature. Speech Tutor Pro — $54.99. Provides pictures, games, and video books for English consonants and vocalic /r/, as well as videos of the sagittal and coronal views for production of consonant phonemes and a few vowels. Picture decks can be created for individual clients, and a data collection feature is included. There is also a Speech Tutor app ($24.99) that provides the videos of phoneme production. Word FLiPS — $29.99. The online version of Super Duper Publications’ Word FLiPS flipbook. Practice CV, CVC, and CVCV targets in real or nonsense words. Data tracking is available.

Other applications that elicit multiple practice opportunities

Cake Doodle — $0.99. The Cake Doodle app (and other “doodle” apps from Shoe the Goose) allows the user to create a cake and decorate it. The user adds each ingredient one at a time, bakes the cake, and adds decorations, thus offering multiple opportunities for practice of functional target utterances (e.g., put it in, put it here, more eggs, I need ___). My PlayHome Series — $2.99–$3.99. The My PlayHome series of apps from My PlayHome Software, Ltd., are enjoyable apps that offer the user opportunities to practice functional words and phrases related to home, school, and community. There are multiple characters in the apps, so the user has multiple opportunities to practice these target utterances. Pepi Play Series — $1.99–$2.99. Pepi Play apps provide the user many opportunities for repetitive practice of functional phrases related to real-life situations (e.g., self-care, going to the doctor, daily living).

131

132   Here’s How to Treat Childhood Apraxia of Speech

Table 3–6.  Progression of Syllable Shape Development Syllable Shapes

Sample Words

V

ooh, oh, ah, eye, ow

C

mmm (yummy), sh (quiet), sss (snake)

CV

me, hi, whee, two, no

VC

up, eight, in, eat

VCV

icky, eeny, icy, owie I go, I see, oh no, oh boy

Reduplicated CVCV C1V1C1V1

mama, dada, booboo, baba

Consonant harmonized C1V1C1V2

mommy, daddy, puppy, baby

Variegated C1V1C2V2

many, happy, movie, doggy no way, boy go, hi cow, me too

Harmonized CVC

pop, mom, dad, nine

CVC

hot, bus, man, book

CVCVCV

banana, potato, tomato we go now, hi daddy, bye pony

CVCVC

button, donut, hopping, magic hi mom, my boat, go home, boy sit

CVCCVC

cupcake, goodnight, helping, basket get down, hot sun, sit down, run home

Double clusters

sp spoon, bl black, gr grape jump mp, tent nt, best st, bats ts

Triple clusters

splash, spl string str masks sks, jumped mped

Multisyllables

alligator, helicopter, jack-o-lantern refrigerator, watermelon

Establishing Flexible Phoneme Sequencing Skills When establishing new syllable shapes, choose targets that incorporate consonant phonemes with different articulatory placement (e.g., bilabials, alveolars, velars), manner (e.g., nasals, stops, fricatives), and voicing (voiced, voiceless), as well as vowel phonemes with varied tongue height (high, mid, low) and tongue advancement (front, central, back). Establishing phonetic variety in terms of place, manner, and voicing is crucial to establishing flexible phoneme sequencing skills. Of course, early targets likely will include early developing phonemes (e.g., p, b, t, d, m, n, h, w); however, the goal is to continue to build the phoneme repertoire to develop maximum flexibility in phoneme sequencing.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   133

Facilitate Targets With Final Consonants and Two Syllables Early in Treatment The CVC and variegated C1V1C2V2 shapes are particularly significant points along the continuum of syllable shape development. Because the English language contains a high percentage of closed syllables (syllables that end in a consonant), developing the ability to produce final consonants in VC and CVC syllables has a positive and dramatic impact on a child’s speech intelligibility. In addition, the number of words containing the variegated CVCV syllable shape vastly exceeds the number of words containing reduplicated or harmonized CVCV syllable shapes. The CVCV shape can also be the basis for early phrase development (e.g., my toy, hi ma, we go). Improvements in both articulatory control and expressive language are facilitated by spending time establishing flexibility and consistency at the variegated CVCV level.

Coarticulation and Efficiency Depending on dialect or speaking context (casual versus formal), English speakers may adjust word productions in connected speech to increase efficiency. Phonemes may be shortened, omitted, or altered in some way in certain coarticulatory contexts, and your modeling should reflect these dialectic differences. Ladefoged (2001) describes several coarticulation rules for English allophones. Some that are important to consider when working on coarticulation are listed next. When modeling target utterances for the child, be sure you are modeling the most efficient productions of the target utterances, keeping in mind these rules of coarticulation: • Alveolar stops /t/ and /d/ are reduced or omitted when they occur between two consonants (e.g., guest bedroom produced as [gɛs bɛdrʊm]; end late produced as [ɛn leɪt]). • Voiceless stops /p, t, k/ are aspirated in the initial position of a syllable (e.g., [pʰɑt] for pot, [tʰɑp] for top, [kʰʌp] for cup). By lengthening the duration of the aspiration during early stages of acquisition of initial voiceless stops, the child has time to coordinate the sensorimotor plan for transitioning from the voiceless phoneme to the voiced vowel that follows. As the child improves, the duration of the aspiration shortens, so the child’s speech sounds more natural. • The voiceless alveolar stop /t/ when followed by /n/ in the same word may be replaced by a glottal stop /ʔ/. The word “mitten,” for example, would be produced as [mɪ.ʔn̩]. • When two identical consonants come next to one another, the first consonant is shortened, though not omitted. In the sentence, “She has very white teeth,” the /t/ in “white” is shortened but is not completely omitted, otherwise it would sound like “why teeth.” • In words with an intervocalic “t” followed by a vowel in an unstressed syllable, as in “butterfly” or “water,” the “t” will change to a quick, lightly voiced alveolar sound known as a flap or tap /ɾ/, as in [bʌ.ɾɚ.flaɪ]. When modeling the word “butterfly,” the “tt” will sound like a quick tap rather than the full alveolar plosive /t/. • In certain contexts, some English words are produced in a shortened manner, either by changing the vowel to a schwa, or by omitting a consonant. Examples are

134   Here’s How to Treat Childhood Apraxia of Speech

and produced as /ən/ or /n̩/ (salt /n̩/ pepper), for produced as /fɚ/ (one /fɚ/ you), or produced as /ɚ/ (apples /ɚ/ oranges), and to produced as /tə/ (went /tə/ the store). The rule does not apply to all productions of these words and is dependent on context and formality. • In some syllables in English, the consonants /m, n, l/ may serve as the nucleus of the syllable; thus, the syllable will not require a vowel. This is referred to as a syllabic consonant and is marked phonetically with a line below the syllabic consonant /m̩/, /n̩/, and /l̩/, as in rhythm /ˈrɪðm̩/, mitten /ˈmɪ.ʔn̩/, and bicycle /ˈbaɪ.sɪ.kl̩/. • When the phonemes /t/ and /d/ are followed by /j/, the sound changes to /tʃ/ or /dʒ/. Examples include congratulations /kən.græ.dʒə.ˈle.ʃənz/; I’ll meet you there. /aɪl.mi.tʃu. ðɛɚ/; Did you do it? /dɪ.dʒu.du.ɪt/; You can ride your bike. /yu.kæn.raɪ.dʒɚ.baɪk/.

Juncture Another way in which coarticulation can be supported is through juncture, or the manner of moving between two successive syllables in speech by pausing, joining the phonemes, or adding a new phoneme. Proper use of juncture can help distinguish between phoneme combinations that sound the same but have different meanings by using either open juncture, in which a short pause is inserted between words in the phrase, or closed juncture, in which there is no pause. For example, a short pause between the words in the phrase, “That’s tough,” would help distinguish it from the phrase, “that stuff,” where the two words would be joined, without a pause between the words. Examples of open and closed juncture are shown in Table 3–7. Words within phrasal units can be joined without pausing. This creates an opportunity for the final phoneme of a word to become the initial phoneme of the following word. This is common when the final consonant precedes a vowel (e.g., “Mom’s at home” produced as /mɑm.zæt hoʊm/; “Put on your coat” produced as /pʊ.dɑn jɔɚ coʊt/; or “Can I do it?” produced as /kæ.naɪ du wɪt/). This type of juncture can be used to the child’s benefit, especially for children who tend to omit final consonants. Using backward chaining, the child can practice “Can I do it” using the sequence shown in Box 3–2. In some instances, phonemes are added between words and syllables to join the words or syllables together. For example, when moving from a retracted vowel to another vowel, the words or syllables are joined with a /j/. When moving from a rounded vowel to another vowel, the vowels are joined with a /w/. Examples are shown in Table 3–8.

Table 3–7.  Open and Closed Juncture Phrases Open Juncture: Pause Between Syllables

Closed Juncture: Syllable Joining

a nice house

an icehouse

stopped aching

stop taking

I scream

ice cream

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   135

Box 3–2.  Backward Chaining Using Closed Juncture /wɪt/ /du wɪt/ /naɪ du wɪt/ /kæ.naɪ du wɪt/

Table 3–8.  Vowel-to-Vowel Juncture With Phoneme Addition From Retracted Vowel to Another Vowel

From Rounded Vowel to Another Vowel

flying = /flaɪ.jɪŋ/

doing = /du.wɪŋ/

she is = /ʃi jɪz/

do over = /du wo.vɚ/

created = /kri.je.ɾɪd/

so it’s = /so wɪts/

Target Utterance Selection The careful selection of target utterances in treatment has a significant impact on treatment success for children with sensorimotor speech planning challenges. Some of these evidencebased treatment programs (described in greater detail in Chapter 4) provide guidance regarding the selection of target utterances. For instance, Dynamic Temporal and Tactile Cueing (DTTC; Strand, 2020) recommends selecting functional words and phrases that facilitate a variety of phoneme combinations to support sensorimotor planning. Rapid Syllable Transition Treatment (ReST; Murray et al., 2015) uses two- to three-syllable nonsense words to support smooth and accurate coarticulatory transitions and correct syllable stress assignment. Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT; Hayden, 2004) treatment protocols use a specific hierarchy of sensorimotor speech development to guide target utterance selection along with a focus on functional communication that will build language and socialization. As clinicians, we should consider several factors when making decisions about target utterance selection, so we are working within the child’s zone of proximal development (ZPD). ZPD refers to tasks a learner is able to do with assistance. This zone falls between what the learner is able to do on their own and what they are not able to do, even with assistance. To work within a child’s ZPD, several factors related to speech and language should be considered. The child’s repertoire of phonemes and syllable shapes and their ability to vary lexical and phrasal stress influence the stimuli to be chosen for the treatment sessions. Additionally, other linguistic, social, and environmental factors have a substantial impact on the clinician’s choice of treatment targets. In fitting within the framework of the World Health Organization’s International Classification of Functioning, Disability, and Health (WHO ICF; WHO, 2007), ideally the target utterances should be motorically, cognitively, linguistically, and socially appropriate for each individual child. Figure 3–2 illustrates five primary factors that should influence the selection

136   Here’s How to Treat Childhood Apraxia of Speech

Figure 3–2.  Factors influencing selection of target utterances.

of target utterances for children with CAS. When each factor is given consideration in the treatment planning and target selection process, there are increased opportunities to facilitate growth not only in the child’s speech intelligibility but also in the child’s expressive language, peer engagement, social development, and self-esteem. In keeping with the framework of the ICF, it is important to incorporate input from caregivers and consider this input alongside the speech-related factors that allow the child to work within their ZPD. Table 13–2 in Chapter 13 provides a parent questionnaire that can be used to solicit input from parents regarding important and functional words/phrases for their child. When reviewing the parent input, you may note that some of the functional words/phrases provided by the parents are well above the sensorimotor planning capacities of the child at this moment in time. Reassure the parents that you will work on those target stimuli for which the child will be able to be successful, and you will continue to expand to more complex targets in the future.

Influence of Current Speech Capacities on Target Utterance Selection Five aspects of speech should be considered when selecting target utterances for treatment. They include the following: • syllable shape complexity (syllable length and complexity, number of syllables) • phonemes (consonant and vowel repertoire and stimulability) • prosody (word and sentence stress patterns) • flexibility and contextual limitations • facilitating contexts Each of these areas is discussed next.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   137

Addressing Syllable Shape Complexity When attempting to challenge the child’s phoneme sequencing skills, Davis and Velleman (2000) recommend choosing words that contain phonemes within the child’s repertoire. If the child is working on improving consistency in production of the VCV and CVCV syllable shapes, consider target utterances that contain phonemes within the child’s repertoire. After the child has demonstrated greater consistency in production of these syllable shapes with well-established phonemes, it would be appropriate to introduce a new phoneme and incorporate that phoneme into CVCV words or phrases.

Addressing Specific Phonemes Reduced consonant and vowel repertoires are a common characteristic of children with CAS; therefore, treatment also will support the child’s attainment of new phonemes. According to Davis and Velleman (2000), new phonemes should be practiced in known syllable shapes, as challenging the child’s sensorimotor skills for phoneme and syllable shape accuracy simultaneously could prove frustrating. When deciding on phonemes to address in treatment, consider selecting phonemes for which the child demonstrates some stimulability. Early on in treatment, consider phonemes that are more visible, such as labials, alveolars, or phonemes that are easy to facilitate through tactile input (e.g., bilabials, vowels requiring lip retraction or lip rounding, or neutral vowels with a simple up-down jaw movement). A more thorough discussion of vowels is found in Chapter 5.

Addressing Prosody When the child has begun to produce two-syllable words, prosody becomes an important consideration. Trochaic stress patterns, in which a stressed syllable is followed by a weak syllable (e.g., potty, table) are more common in English language than iambic stress patterns, in which a weak syllable is followed by a stressed syllable (e.g., alone, forgot). In English speech, trochaic words tend to be easier for children to produce than iambic words. When introducing two-syllable words into treatment, begin with words with trochaic stress before moving to words with iambic stress. As the child progresses, provide more opportunities for the child to practice a wider variety of prosodic patterns. More detailed information on prosody is found in Chapter 5.

Addressing Flexibility, Contextual Limitations, and Facilitating Contexts Children with CAS often demonstrate contextual constraints in their phoneme production. For example, a child may be able to produce /b/ and /p/ but only in certain facilitating contexts, such as in the initial position when followed by the /ɑ/ vowel (e.g., baba, papa). When choosing target utterances for treatment, consider the child’s contextual limitations and choose targets with vowels in neighboring vowel spaces, as in ball or buhbuh for bubble, or try to expand to final position, as in up or pop. Research findings regarding facilitating contexts can help guide our choices in determining treatment targets. Table 3–9 describes some of the research findings related to facilitating contexts and provides suggestions for treatment targets based on this research.

138   Here’s How to Treat Childhood Apraxia of Speech

Table 3–9.  Research Findings Related to Facilitating Contexts Research Reference

Research Finding

Potential Targets

Kehoe & Stoel-Gammon (2001)

Children produce final consonants in syllables more frequently when the final consonant follows a lax vowel /ɪ, ɛ, æ, ʊ, a, ə, ɚ/ than a tense vowel.

“hit” “mess” “book” “cup” “catch”

Children attain voiceless obstruents /p, t, k, f, θ, s, ʃ, tʃ/ earlier than other phonemes in word final position. Velleman (2002)

Theoretical construct of coarticulation

Fricatives and velars may be easier to elicit in final position than initial position of words.

“back” “rug” “tough” “bus” “push”

Children tend to produce the high front vowel /i/ in the second syllable of CV.CV words.

“mommy” “daddy” “baby” “bunny” “happy”

Use well-established initial consonants to facilitate the same consonants in the final position.

“home made” “bad day” “fish shop” “goes zoom” “big game” “truck key” “tough fish”

Use well-established final consonants to facilitate the same consonants in the initial position.

Davis & MacNeilage (1990, 1995)

Alveolar consonants tend to co-occur with high front vowels /i, ɪ/.

“tea” “sit” “lead”

Labial consonants tend to co-occur with central vowels /a, ʌ, ə/.

“pup” “mama” “bah”

Velars tend to co-occur with back vowels /u, ʊ, o, ɔ/.

“cook” “go” “goo”

Influence of Language on Target Utterance Selection Children with CAS often demonstrate expressive language challenges. Therefore, it is important to consider the child’s linguistic needs when selecting target utterances. Several linguistic factors should be considered when selecting target utterances for treatment of children with CAS.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   139

Parts of Speech When selecting targets for treatment sessions, be sure your selected targets represent a wide range of parts of speech. Typically, children’s first 10 words represent labels for objects or people within the environment, with the next 40 words representing a mix of labels, action words, modifiers, and function words (Nelson, 1973; cited by McCormick & Schiefelbusch, 1984). Too often, however, nouns make up the bulk of vocabulary introduced as target words in a child’s treatment, primarily because it is easier to find pictures that represent objects. An overrepresentation of nouns, however, limits opportunities for facilitation of phrases and sentences.

Semantic Relations By selecting a range of vocabulary representing different parts of speech, the SLP provides the child with a vocabulary set from which to formulate a variety of early semantic relations (e.g., my puppy, puppy in, puppy go, tiny puppy, no puppy). Chosen phrases should mirror language development norms for how children learn to combine words. Chapter 6 of this book provides greater detail about the role of semantic relations in facilitating early phrase development in children.

Grammatical Morphemes Consider the order of acquisition of grammatical morphemes (Brown, 1973) when selecting target utterances for treatment. The morphemes described by Brown include the following: • -ing present progressive tense (e.g., “Daddy working.” “I sleeping.”) • “in” and “on” marking location (e.g., “baby in buggy” “go on swing”) • -s marking regular plural noun (e.g., “my dolls” “more bubbles”) • Early irregular past tense verbs (e.g., “Mommy went store.” “I ate it.”) • -’s possessive noun (e.g., “mommy’s coat” “Go Daddy’s car.”) • “am,” “is,” “are,” was,” “were” uncontracted copula forms of to be (e.g., “My ball is big.” “That was silly.”) • “a” and “the” making distinction between definite and indefinite referents (e.g., “here the ball” “that a book”) • -ed marking regular past tense verbs (e.g., “I jumped.” “Mommy helped me.”) • -s third person regular tense verbs (e.g., “Cow sleeps here.” Baby wants more.”) • “is,” “has,” “does” third person irregular verb forms (e.g., “Doggie has bone.” “He does.”)

140   Here’s How to Treat Childhood Apraxia of Speech

• Uncontractible auxiliary verbs (e.g., “Mommy is cooking dinner.” “I am going home.”) • Contractible copula forms (e.g., “It’s my toy.” “He’s so funny.”) • Contractible auxiliary verbs (e.g., “Daddy’s coming home.” “Doggie’s riding a bike.”)

Influence of Environmental Factors on Target Utterance Selection Carryover of the skills learned within the context of treatment is a primary goal for speech and language therapy; therefore, environmental factors related to the settings where children spend most of their time (home, school, community) need to be considered when choosing treatment targets.

Home Environment The people, routines, and values within the home setting will influence the selection of target utterances for each child. Names of people and pets living within the home or with whom the child has regular contact are important targets. Ask parents and caregivers about family routines and regular activities of the child and family to determine targets that may be functional for the child within the home setting. Holiday celebrations, special events, and religious or cultural traditions also may influence the vocabulary to which the child is exposed in the home environment. Selecting targets that reflect the types of activities the child participates in within the context of the family serves important functions including the following: • increases the functionality of the vocabulary • increases opportunities for practice outside the context of therapy • increases the child’s motivation to use the vocabulary outside the context of therapy • increases family members’ awareness of the gains the child is making in therapy • increases opportunities for praise and validation of the child’s hard work

School Environment Selecting target utterances that provide opportunities for children to participate more fully at school is important. Being able to produce more utterances with greater clarity in the school environment supports children in the following ways: • increases opportunities for children to show what they know • increases opportunities for interaction with peers • increases self-esteem • increases peer acceptance • reduces reliance on adults as communicative partners. A study by Rice et al. (1991) showed that children with limited communication skills tended to initiate language far less than their normal peers and directed their language to adults far more frequently than to their peers.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   141

Target vocabulary for young children may include names of teachers and favorite classmates, terms used within specific thematic units, and toys and activities with which the child plays regularly. A fourth-grade child with CAS may have a speech goal of improving production of multisyllabic words. If the child is preparing to give an oral report to the class on the topic of tigers, it would be beneficial to practice words from the report such as “habitat,” “predator,” “Africa,” and “nocturnal.” The desire to speak clearly when presenting this report may facilitate motivation to practice these words and is more functional than practicing an arbitrary list of words during treatment.

Community Children’s communicative needs vary depending on the types of activities in which they participate and the places they go within their communities. Children may participate in recreational activities and social activities, attend birthday parties, visit favorite restaurants, or attend a place of worship within their community. Choosing target utterances that support the child’s ability to communicate within a wide range of settings within the community, such as being able to order a meal at a favorite restaurant, serves an important function for the child.

Influence of Motivation on Target Utterance Selection Children will make greater progress if they are motivated to work hard in therapy. Research has shown a strong correlation between emotion and learning. Children are more apt to experience positive emotions in connection with activities that interest them. When children experience strong positive emotions within the learning process, their ability to attain and retain the information is increased (Vail, 1993). Although some children may love to engage in imaginative play with animal toys, superheroes, or dolls, others may prefer expressing themselves through art, building, or movement activities. Asking a child who loves to run, swing, and climb to sit at a table and place animal puzzle pieces into a puzzle could prove to be frustrating for both the child and the clinician and lead to less positive learning outcomes. Find out from the child, family, or teachers what motivates and interests the child. Consider these interests when selecting target utterances for treatment.

Influence of Socialization on Vocabulary Selection Another overriding goal for the treatment of children with communicative disorders is to facilitate opportunities for improved social language development. It is important to consider the social implications when selecting target utterances.

Language Functions Verbal communication opens opportunities for increased social interaction for children. Typically developing children naturally use language for a wide range of communicative functions. Several communicative functions are listed in Table 3–10, along with suggested target words or phrases to facilitate the use of the specific communicative functions. Although this is not an exhaustive list, it does provide another tool for considering how we, as SLPs, determine

142   Here’s How to Treat Childhood Apraxia of Speech

Table 3–10.  Communicative Functions and Corresponding Target Utterances Sample Worksheet Communicative Function

Targets To Elicit Communicative Function

Greeting/closing

Hi, hello, Hey, Goodbye, Bye, See ya later

Requesting objects

More _____, I want _____, Can I have _____

Requesting actions

Go get _____, Do this

Requesting attention

Look at me, Watch this

Rejecting

No, I don’t want _____, All done

Asking for information

Where is _____? How do you _____?

Requesting assistance

Help me, I need help, Can you _____?

Asking permission

Can I _____? May I _____?

Disagreeing

I don’t think so, That’s not right, Not me

Protesting

Stop, Don’t _____, No

Sharing information

Guess what, Let me tell you about_____

Commenting

Me too, Mine’s faster, Cool, Yucky, Sorry

Responding to questions

Yes, Yeah, Uh huh, Mmm Hmm, No, Uh Uh, I don’t know

Self-advocacy

I need a break, Stop that, That hurts, My turn, Go away, Not now

which target utterances to incorporate into our treatment sessions. A blank worksheet that lists communicative functions with blank spaces to fill in targets to elicit those functions is included in Appendix 3–A. Children will be more likely to utilize a wider range of communicative functions if they have the vocabulary with which to do so. For example, if a child is not using the greeting function, it may be appropriate for the child to practice producing “Hi,” “Hey,” or “Hello” in treatment. A child who becomes easily frustrated may not have the words at their disposal that allow to protest or express feelings. Teaching words or phrases like “no,” “stop,” “too hard,” “I’m mad,” or “all done” helps give the child ways to protest and express feelings.

Conversational Skills Target utterances can be selected to facilitate a child’s ability to participate more fully in conversations. The three primary interactions used between conversational partners include the following: • asking appropriate questions to gain new information about the conversational partner • making comments to let the partner know you are listening and interested • providing new information about yourself, either spontaneously or in response to a specific question

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   143

To support a child’s ability to ask appropriate questions, treatment targets may include “what,” “where,” “who,” “when,” and “why” or “do you,” “is it,” “can I.” Teaching words and phrases like “cool,” “wow,” “too bad,” or “I’m sorry” can facilitate the use of commenting. “Not me,” or “me too” would support a child’s ability to provide new information about themselves in the context of a conversation. Chapter 8 provides more detailed information to support social language skill development and conversational skills as children get older.

Practice Activity in Selecting Target Utterances A child with CAS is described in this section. The child’s phoneme repertoire and syllable shape variety along with language information, environmental influences, specific interests, and social skills/needs are listed in a Target Utterance Selection Considerations Worksheet in Table 3–11. All this information influences target utterance selection and should be considered when making decisions about the target words and phrases that will be practiced during intervention. Table 3–12 displays a completed Intervention Plan Worksheet, which illustrates how the various influential factors are considered collectively in planning treatment activities and choosing stimuli for a lesson. A blank Target Utterance Selection Considerations form and an Intervention Plan Worksheet form are provided in Appendix 3–A.

Target Utterances During Play When working with a child in a school, a clinic, or the home, favorite toys and activities can be used to elicit meaningful and functional target utterances. Box 3–3 provides a few examples of simple target utterances that can be incorporated into treatment when playing favorite and familiar games and activities. Of course, the choice of targets will be based on the child’s phonemic and phonetic capabilities. Notice how the target utterances incorporate vocabulary from various parts of speech, rather than primarily focusing on object labels.

Table 3–11.  Target Utterance Selection Considerations Worksheet Sample Form TARGET UTTERANCE SELECTION CONSIDERATIONS WORKSHEET Name:  Lisa B. Age:  3 years, 6 months Speech →

Phoneme repertoire:  /b, d, m, n, h/; /u, o, a, ʌ/ Word shapes:  CV; CV.CV reduplicated

Language →

Single words

Environmental →

Lives with mother, father, and baby sister, Jessica. Visits grandparents weekly

Interests →

Balls, farm animals, dolls, toy people, outdoor play

Social →

Requests, rejects, labels, responds to, but does not ask questions; robust gestural system

144   Here’s How to Treat Childhood Apraxia of Speech

Table 3–12.  Intervention Plan Worksheet Sample Form Intervention Plan Worksheet Name:  Lisa B. Date: 1-27-2023 Word Shape(s) CV Harmonized CV.CV V (using diphthongs) Phoneme(s) C and V

Social/Pragmatic Goals Greet/close; comment; request

Vocabulary; Phrase Structures bee, me, ow, mommy, daddy, baby, bubble, more, high, uh oh Facilitate phrases if possible (e.g., “Hi/bye mommy/daddy/ baby.” “more bubble(s)”)

/b, d, m, h/ /i, e, o, ɔ, ɑ, ʌ, ʊ,/ Materials

Activities

Baby Bumblebee song book

Sing “Baby Bumblebee” song. Facilitate production of /i/ vowel in “me” and “bee” and the diphthong /aʊ/ for “ow”

Animal Families (baby, mommy and daddy animals)

Build a zoo and sort the animals. Facilitate harmonized CV.CV by labeling “baby,” “mommy,” and “daddy” animals

Bubbles

Play with bubbles. Facilitate harmonized CV.CV for “bubble” /bʌ.bo/, diphthong /aɪ/ for “high,” /ɔ/ for “more”

Box 3–3.  Examples of Target Utterances for Various Play Activities Playing With Toy Food or in a Toy Kitchen eat; I eat; you eat; mommy eat; more ___; tea; I do; cup; bowl; pour; stir; open; cut; hot; dirty; wash; in; on; here you go; apple; banana; cookie; names of other foods/drinks; water/wawa; beep/ding (sound of timer going off); pan; pot; yum/yummy; yuck; yucky; turn on; ready; all done; all gone Playing With Puzzles out; in; me; you; help/help me/I need help; no; here/go here; put; put here; piece; not there; turn/turn it; I do it; Let me do it; labels of puzzle piece pictures Games for Young Children (e.g., Lucky Ducks by Pressman) duck; ducky; duck in; my turn; your turn; you do; I do; in water; put in; wet; on; turn on; push; colors (red; yellow; purple; blue); yay; match; not match; number words for counting Bubbles bubbles; pop; blow; again; up; down; in; out; wet; sticky; yucky; big; small/tiny; I do; you do; wow; uh oh; oh no; messy; all done Playground/Park up; go; I do/I do it; by myself; help/help me; whee; push; high; low; fast; slow; too fast; up; down; sit; swing; slide; spin; climb; go; jump; run; ball; bird; tree; ow; ouch; hurt; boo boo

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   145

Multisensory Cueing and Feedback Providing multisensory cues and specific feedback is one of the cornerstones of the successful provision of treatment for children with CAS. The SLP may be following the best treatment practices: selecting appropriate vocabulary, creating opportunities for multiple repetitions of target words, and providing an intensive treatment schedule. However, if the cues being provided to the child from trial-to-trial in treatment are not carefully selected based on each of the child’s responses and patterns of errors, progress will not be realized. It is hypothesized that children with CAS may have poor feedforward programs (anticipatory sensorimotor plans) and thus rely on auditory feedback (Terband et al., 2009) to increase accuracy of speech productions. A study by Iuzzini-Seigel et al. (2015) compared speech production parameters in children with CAS, speech delay, and typically developing speech when auditory masking was introduced during speaking. The auditory masking made it difficult for children to employ auditory feedback to monitor their speech productions. Their findings further supported the premise that children with CAS are more reliant on auditory feedback than typically developing or speech delayed children. Looking in the rearview mirror at an utterance that already has been produced, however, is an inefficient way to facilitate better speech production. In addition, many children with CAS, particularly those children with CAS and language impairment, have been found to have poorer speech perception skills than typically developing children or children with CAS only (Zuk et al., 2018). Because reliance on auditory feedback is inefficient in the process of speech, and because many children with CAS evidence poor speech discrimination skills, it is essential that SLPs provide cueing (including visual, tactile, and proprioceptive) that facilitates greater internal representations of the sensorimotor speech plans so they are not reliant on auditory feedback for accurate productions of target utterances. A wide variety of cues that help children gain greater sensorimotor control of speech are described in the next sections.

Primary Types of Cues Use of multisensory cueing is a common theme of many therapy techniques for CAS. All sensorimotor-based treatment programs for CAS encourage the child to watch and listen to the clinician model the target utterances and attempt to imitate the model. If the child does not respond correctly, other types of cues are provided. The cues provided may include the following: • visual (a visual model or image of the way the mouth looks during production of the target utterance) • auditory (an auditory model of the target utterance) • tactile/kinesthetic/proprioceptive (what the child feels during production of the target utterance) • metacognitive (an associative cue that helps the child focus on a specific aspect of the target utterance)

Visual Cues Visual cues show the child how the mouth looks during production of the target utterance. The child receives a visual cue when they watch the clinician’s face while the clinician is

146   Here’s How to Treat Childhood Apraxia of Speech

modeling a target utterance or when they observe themself in a mirror during production of the utterance. Static photos or drawings of a specific lip or tongue position and videos of target utterance productions also may serve as visual cues.

Auditory Cues Auditory cues are those cues that allow the child to listen to a verbal model of the target utterance.

Somatosensory (Tactile, Kinesthetic, and Proprioceptive) Cues Tactile cues relate to the sense of touch on the skin. During speech, we receive tactile input from the articulators contacting one another (e.g., lip contact when producing bilabials; tongue to alveolar ridge contact while producing alveolars). In treatment, clinicians can provide tactile cues to increase the child’s awareness of the feel of the articulators during specific articulatory configurations. Kinesthetic awareness is the body’s internal sense of movement. Proprioception is the internal sense that helps a person recognize the amount of effort or force with which the body is moving, the speed of movement, and how the different body parts are moving in relation to one another in space. By reducing the rate of speech production or by holding an articulatory posture slightly longer, you increase kinesthetic and proprioceptive awareness of speech movements, the positioning of the articulators, and the relationship of the articulators to one another in space.

Metacognitive Cues Metacognitive cues provide the child ways to think about speech movements either through specific instruction or through some type of associative cue. Metacognitive cues encompass many of the cues described in this chapter. They include such strategies as providing phonetic placement cues (“Lift the back of your tongue to make the ‘k’ sound”), tapping out syllables of a word to reduce syllable deletion, and using metaphors (“Be sure to use your ‘humming sound’ at the end”) to facilitate the use of a specific phoneme or combination of phonemes. For metacognitive cues to be effective, the child must already have an internal representation of the sensorimotor plan. The cues simply provide a way for the child to access the sensorimotor plan. It has been our experience that when metacognitive cues are paired with visual, auditory, and/or tactile cues early in treatment, the clinician can begin to fade from the more salient visual, auditory, and tactile cues to the less salient metacognitive cues. For example, the clinician can pair a direct model for the word “go” with a tactile cue to facilitate lip rounding, as well as a metaphor cue “be sure to use your circle lips,” then begin to fade the model and the tactile cue and provide only the metaphor cue to trigger an accurate response from the child. By laying down a variety of metacognitive cues for a child, the child eventually develops greater internal access to these cues and can call upon them as needed to achieve an accurate production.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   147

The Use of Multisensory Cues in Treatment of CAS Clinicians typically provide a variety of cues to facilitate accurate production of target utterances. The cues provided by the SLP help a child learn to focus their attention on the specific change(s) required to eventually achieve accurate production of all aspects of the speech movement. Determining the most salient aspect of the speech movement depends on where the breakdown in speech accuracy is occurring. For example, a child who is reducing a two-syllable word (bunny) to a single syllable (bu) may benefit from a metacognitive cue (two blocks) as a reminder to incorporate both syllables in the target word. The child who pronounces “bunny” as “nunny” may benefit from a tactile cue to the lips to facilitate lip closure for the /b/ and reduce the assimilation. Table 3–13 provides a way of sorting the cues based on which sensory system(s) is being engaged during the cueing process. During the evaluation and diagnostic treatment processes, the SLP can determine which types of cues are most beneficial for a specific child.

Descriptions of Multisensory Cues Each of the cues listed in Table 3–13 is described in the following sections to better understand how the various cues are applied in the context of treatment.

Direct Imitation and Delayed Imitation The clinician models the target for the child prior to the child producing the target. Modeling provides both auditory and visual cues that fire up mirror neurons when the clinician secures the child’s visual attention prior to modeling the target. Initially, the child will imitate the target immediately following the model (direct imitation). As the child progresses, a delay of 1 to 3 s after the model can be added prior to the child producing the target (delayed imitation). This delay can be achieved by one of the following: • producing the model but signaling for the child to wait before producing the target utterance • embedding the model in the context of the instruction (e.g., “Puppy is the next word.” or “Let’s say ‘bye’ to all the animals. Bye cow. Now you try it.”) For children who are easily visually distracted, a box or wide tube can be placed around the face of the clinician, so the child is encouraged to look only at the clinician’s face and not become distracted by other things in the treatment space. Some children, including but not limited to children with autism, may have trouble focusing on the face (particularly the eyes) of the person modeling. Using a shield to hide the eyes of the person modeling (e.g., a folder or index card) may encourage better visual attention to the clinician’s mouth.

Video Modeling With video modeling, rather than watching the clinician in real time, the child views videos of people modeling the target utterances. Some children may find it easier to attend to video models. The video modelers are not limited to the clinician but can include the parents and

148   Here’s How to Treat Childhood Apraxia of Speech

Table 3–13.  Multisensory Cues for Treating Children With CAS Associated Sensory Systems

Cueing Technique

Visual (child sees a model of production)

Rate reduction

Auditory (child hears a model of production)

TactileKinestheticProprioceptive (child is provided with tactile input)

√

√

Simultaneous production

√

√

Direct imitation and delayed imitation

√

√

Mirror

√

√

Mime

√

Backward chaining

√

√

Forward chaining

√

√

Metacognitive (child is provided with an associative cue)

Hand cues for place, manner, voicing

√

Manual signs

√

Graphic cues

√

Tapping/clapping syllables

√

Blocks/chips

√

Metaphors

√

Phonetic placement cues

√

Mouth pictures and videos

√

√

Visual syllable words

√

Tactile-kinestheticproprioceptive cues Visual biofeedback (ultrasound biofeedback, electropalatography, video modeling)

√ √

√

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   149

other family members. An added benefit of video modeling is that the videos can be viewed during the treatment sessions as well as outside the sessions during home practice.

Simultaneous Production The child and clinician produce the target utterance simultaneously. During simultaneous production, the clinician and the child produce the target utterance together at the same time. The DTTC approach (Strand, 2020), described in greater detail in Chapter 4, utilizes simultaneous production as a way of facilitating the correct production of challenging targets when direct imitation alone does not elicit an accurate production. It is the difference between “Say it after me” (direct imitation) and “Say it with me” (simultaneous production). Simultaneous production is used only to achieve initial acquisition of the target utterance for a few productions and then is faded and replaced with a less salient cue, such as direct imitation or miming.

Miming The child watches the clinician while the clinician produces the target utterance without voice. Although simultaneous production engages both the visual and auditory systems, miming engages only the visual system, making it a less salient cue. If a child is producing the target accurately with simultaneous production, the clinician may continue to model the word along with the child, but without voice, to see if the child is able to maintain accurate productions when the auditory cue is removed.

Rate Variations Rate variations involve cueing the child to say the utterance at a reduced rate of speech and gradually increasing the rate until the sound combinations can be produced accurately at a normal rate. Children can be cued to reduce their rate by doing one of the following: • during direct imitation or simultaneous production, the clinician models the target utterance at a reduced rate • the clinician reminds the child to use a reduced rate by incorporating associative cues, such as • hand signals • verbal reminders • picture cues (e.g., turtle or snail) • pacing board

Although rate reduction is beneficial for facilitating correct productions of targets within the practice setting, it is essential to gradually increase rate to approximate a normal rate of speech. The gradual increase of rate provides the learner with greater opportunities for generalization of the target in other settings and in the context of typical conversational speech. There is a phenomenon in the acquisition of sensorimotor skills known as “speed-accuracy trade off, meaning simply that when performers attempt to do something more quickly, they typically do it less accurately” (Schmidt & Lee, 2005, p. 33). Some children, especially

150   Here’s How to Treat Childhood Apraxia of Speech

children with severe CAS, may not be able to achieve a rate of speech that matches their typically developing peers without substantial reduction in accuracy and intelligibility. Helping children establish a rate of speech that still allows for the best possible speech intelligibility may be required for children with more profound speech challenges.

Mirror The child watches in the mirror while producing the word. Having a child observe themselves in a mirror while producing the target may be beneficial, particularly for establishing sounds and sound sequences that are highly visible. The mirror serves to facilitate the use of appropriate movement gestures and to inhibit the use of incorrect movement gestures. For example, a child working on lip rounding during production of /w/ can watch themselves in the mirror to facilitate lip rounding for /w/. A child who tends to protrude his tongue when producing /l/ may use the mirror to inhibit tongue protrusion during /l/ production. It is essential that the child not become dependent upon the mirror for cueing, as the auditory and tactile/kinesthetic feedback should serve a greater and greater role in facilitating stronger internal representations of correct versus incorrect production of target utterances. Nevertheless, in initial stages of practice, the mirror can be helpful in facilitating or inhibiting articulatory movement gestures for accurate speech production.

Backward Chaining The clinician models a multisyllabic word, a word containing an initial or final cluster, or a phrase by starting at the end of the utterance, producing the final sound, syllable, or word first, and moving from the back of the word to the front of the word in progressively longer units. The use of backward chaining has been suggested by Chappell (1973) and Velleman (2003). Table 3–14 illustrates the use of backward chaining for facilitating correct production of consonant clusters, multisyllabic words, and sentences. When using backward chaining, it is essential to model the correct stress and intonation of the syllables and words in the utterance. In the examples that follow, the words and syllables in bold type would receive greater relative stress than the other words and syllables in the utterances. Table 3–14.  Examples of Backward Chaining Backward Chaining to Elicit Cluster

Backward Chaining to Elicit Multisyllabic Word

Backward Chaining to Elicit Multisyllabic Word In Sentence

ick

ber

la

tick

tober

brella

stick

October

umbrella my umbrella got my umbrella forgot my umbrella I forgot my umbrella.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   151

Forward Chaining The clinician presents a multisyllabic word or a word containing an initial or final cluster by starting at the beginning of the word, producing the initial sound or syllable, then moving from the front to the back of the word. Children may benefit from practicing portions of the word in smaller segments and adding sounds or syllables as they are able to manage the increased word shape complexity. If the target word is ladybug, the child may practice producing “lay,” then “lady,” then “ladybug.” For a word with a final cluster such as hops, the child may practice producing “hop” and then be cued to add the /s/ to the end of the word to produce the target word, “hops,” correctly. Table 3–15 provides other examples of forward chaining. Preston et al. (2019) describe a combination of both backward and forward chaining in a Speech Motor Chaining procedure for children with speech sound disorders, including children with CAS. A five-step process of moving from a CV or VC target to a self-generated sentence is used as the child attains various CV and VC combinations of challenging target phonemes. For example, a child working on /r/ may have a motor speech chain with these targets (ra, rot, rotten, rotten food) and then a self-generated sentence with “rotten food” or these targets (or, for, before, just before) and a self-generated sentence with “just before.” The focus of chaining is facilitating flexible movement patterns — that is, moving from the challenging phoneme into and out of adjacent vowels with varied tongue height and advancement or consonants with varied place/manner/voicing. It is best to work from the contexts that are most facilitative to least facilitative for the particular child. Table 3–16 provides examples of building flexible movement gestures when working on challenging phonemes. The child works from the most facilitative context, in this case /ts/ followed by a vowel, toward more challenging contexts (e.g., /ts/ followed by /g/, as they differ in place, manner, and voicing). In the case of the /sk/ cluster, the child begins by moving from a vowel to /sk/ (most facilitative context) toward /k/ to /sk/, which is a challenging context for the child.

Hand Cues The clinician uses specific finger/hand positions or hand motions representing a specific articulatory placement, lip shape, or manner of production of a phoneme or series of phonemes to cue the child to produce that phoneme or sequence of phonemes accurately.

Table 3–15.  Examples of Forward Chaining pull

police

policeman

but

butter

butterfly

base

baseball

baseball bat

bat

batter

battery

soup

super

Superman

spy

spider

Spiderman

me

meaty

medium

152   Here’s How to Treat Childhood Apraxia of Speech

Table 3–16.  Examples of Chaining Movement Gestures for /s/ Clusters Target /ts/

/ts/ to V

/ts/ to /s/

/ts/ to /j/

/ts/ to /w/

It’s

It’s a It’s a new day.

It’s so It’s so cool!

It’s your It’s your turn.

It’s way It’s way too hard.

/ts/ to /n/

/ts/ to /m/

/ts/ to /tʃ/

/ts/ to /h/

/ts/ to /g/

It’s nice It’s nice to meet you.

It’s my It’s my turn.

It’s chilly It’s chilly in here.

It’s her It’s her coat.

It’s going It’s going to rain.

Target /sk/

V to /sk/

/z/ to /sk/

/t/ to /sk/

/n/ to /sk/

School

to school Go to school now.

his school I like his school.

night school He went to night school.

in school We are in school all day.

/m/ to /sk/

/p/ to /sk/

/l/ to /sk/

/f/ to /sk/

/k/ to /sk/

Some schools Some schools are not open yet.

keep school Keep school closed this week.

until school One minute until school begins.

tough school He did a tough school project.

like school Do you like school?

Any hand position or hand motion that is meaningful to the child and offers the necessary reminders for production of a speech movement or movement sequence is appropriate. Hand positions and hand motions can be used to reference individual consonant or vowel phonemes or can be combined to facilitate accurate production of movement sequences for production of consonant clusters, syllables, or entire words. Hand cues can be provided alone or while modeling or miming the target utterance. Refer to Table 3–17 for suggestions of hand cues that help to facilitate accurate phoneme placement (e.g., child substitutes /ti/ “tea” for key) or lip shape (e.g., facilitating lip rounding for accurate production of /u/). Table 3–18 provides suggestions of hand cues to facilitate the child’s accurate manner of production (e.g., child substitutes /toʊp/ for soap). The suggested hand cues provided here tend to be transparent — that is, they suggest the place or manner of production of the specified phonemes. Some materials for children with speech disorders recommend hand cues that are more arbitrary and do not relate to the placement or manner of articulatory production. Try different gestural cues until you find cues that are meaningful for the individual child. The cues described in Tables 3–17 and 3–18 provide suggestions for gestures that have been beneficial in the treatment of children with CAS. Some children, however, benefit from bigger, more robust gestures. For example, the vowels /o/ and /u/ may be cued by shaping two hands together like a broad circle and extending them forward from the face. The vowel /i/ may be cued by pointing your fingertips toward the corners of the mouth and moving both arms sideways away from the mouth, whereas the /ɑ/ vowel would be cued by pointing your fingertips toward the lower lip and dropping the arms straight down toward the chest. Marshalla (2009a, 2009b) has created YouTube videos, Pam’s Place Cues — Vowels and Pam’s Place Cues — Consonants, that demonstrate hand gestures for many consonant and vowel phonemes (https://www.youtube.com/watch?v=4te9DY1jTc8; https://www.youtube.com/watch ?v=lBclowP9uds). They may be helpful when trying to establish hand signals for your students.

Table 3–17.  Suggested Hand Cues to Reference Place/Shape of Articulation Phonemes

Suggested Hand Cues

/p/, /b/, /m/

Place index finger along lip line.

/t/, /d/, /n/

Place the tip of index finger at the center of philtrum.

/k/, /g/

Place four fingertips under chin near throat.

/f/, /v/

Bite lower lip and place the tip of index finger at the center of lower lip.

/h/

Place an open palm in front of open mouth.

/s/, /z/

While smiling widely, place index finger and thumb at the corners of lips.

/ʃ/, /ʒ/, /tʃ/, /dʒ/

Protrude lips and place index finger and thumb at the pads of cheeks.

/l/

Place index finger just below the center of upper teeth.

/r/

Place index finger and thumb near the back of throat.

/i/

Place index fingers at opposite corners of lips while smiling.

/u/

Place index fingers at opposite corners of lips while shaping lips in a tight circle or gesture with index finger in a circular motion around lips.

/oʊ/

Place index fingers at opposite corners of lips while shaping lips in a more open circle or gesture with index finger in a circular motion around lips.

/ɑ/

Place index finger at the center of chin and lower jaw.

Table 3–18.  Suggested Hand Cues to Reference Manner of Articulation Phonemes

Suggested Hand Cues

/p/, /b/

Hold the tips of all fingers and thumb together near the corner of lip and release them quickly to represent a puff of air.

/m/

Place index finger at the side of nose while modeling /m/.

/t/, /d/

Hold the tips of thumb and index finger together near the center of lips and release quickly.

/n/

Place index finger at the side of nose while modeling /n/.

/k/, /g/

Place four fingertips at the back of throat and quickly release them forward while producing these phonemes.

/f/, /v/

Bite lower lip and then move index finger back and forth along the edge of the lower lip.

/h/

Place one hand flat against chest and one open palm (either the therapist’s or the child’s) in front of open mouth to feel the sensation of air.

/s/, /z/

Slide index finger along the length of upper lip or up the length of forearm.

/ʃ/, /ʒ/

Protrude lips and place index finger and thumb at the pads of cheeks moving fingers forward while producing these phonemes.

/tʃ/, /dʒ/

Hold the tips of all fingers and thumb together near the side of cheek and release them quickly to represent a puff of air.

153

154   Here’s How to Treat Childhood Apraxia of Speech

Manual Signs The clinician signs words just prior to or while the child is producing the words. When a manual sign has been linked to a verbal model repeatedly, the verbal model can be faded, and the sign will still act as a cue to trigger the child’s motor memory for how the target is produced. Phrases or specific words within phrases may be signed to the child as the child is speaking. Manual signs may be particularly effective for children who tend to omit function words (e.g., articles, prepositions) or morphological markers (e.g., present progressive “ing,”).

Graphic Cues The clinician incorporates letters, written words, or phrases denoting specific sounds or words in treatment. Using graphic cues can remind a child who is able to recognize and make sense of the written information to insert sounds where they are needed in words. Written words can help draw a child’s attention to a specific phoneme or sequence of phonemes within a word. Target phrases can be written on sentence strips to support accurate productions of the target phrase. For prereaders, graphic cues can be used to support later literacy development. More detailed information regarding ways to support early literacy development within the context of speech praxis treatment is included in Chapter 7. When using graphic cues, using bold type, underlining, highlighting, or enlarging certain phonemes can be used to bring a child’s attention to specific elements of the target utterance. Some learners also respond to alternative spellings to help sound out the words. Examples are shown in Box 3–4.

Syllable Cues The clinician and/or the child taps or claps out the number of syllables in the word or phrase or uses blocks or other tokens to denote those syllables. Syllable cues are used when a child omits syllables from multisyllabic words or words from phrases by alerting the child to the correct number of syllables. Simply clapping hands for each syllable or tapping on the table, your knees, or a drum may provide a salient enough cue to facilitate inclusion of all syllables within the target word or phrase. Blocks or chips provide similar cues. Different-sized blocks can be used to denote syllables versus whole words or to differentiate stressed from weak syllables. For example, in Figure 3–3, the child is practicing the target word “banana” in the carrier phrase “I ate a __________,” with large blocks used to denote whole words and small blocks to denote individual syllables of the word banana. When using syllable cues, be sure to model normal prosody to avoid robotic sounding productions. Box 3–4.  Examples of Graphic Cues

What’ss your name? He sat on a hat. We created a map of Ireland. Kree yay did

eye yurr lind

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   155

Metaphors Rather than modeling the target word for the child, the clinician cues the child to produce a particular phoneme using a term that describes some feature of the phoneme. Bleile (2006) uses the term metaphor as an analogy for production of a specific phoneme. Choosing metaphors that reflect a manner of production or an articulatory placement increases the saliency and meaningfulness of the cue. Table 3–19 provides examples of metaphors for many phonemes.

Figure 3–3.  Using blocks to denote words and syllables. Table 3–19.  Suggested Metaphors Associated With Specific Phonemes Phoneme

Metaphor

Phoneme

Metaphor

/b/

Submarine sound Noisy lip popper

/s/

Shy snake sound Quiet skinny air

/p/

Popcorn sound Quiet lip popper

/z/

Buzzing bee sound Noisy skinny air

/m/

Yummy food sound Humming lips

/ʃ/

Sleeping baby sound Quiet big air

/w/

Crying baby sound Lip squeezer

/tʃ/

Choo-choo train sound Big air popper

/d/

Drumbeat sound Noisy tongue tapper

/dʒ/

Noisy choo-choo sound Big air popper

/t/

Tick-tock clock sound Quiet tongue tapper

/θ/, /ð/

Brave snake sound

/n/

Noisy nose sound

/r/

Growling bear sound

/l/

Singing sound Teeth hugger

/k/

Coughing sound Quiet throat sound

/f/

Windy sound Quiet lip biter

/g/

Drinking sound Noisy throat sound

/v/

Car engine sound Noisy lip biter

/h/

Panting dog sound Warm air sound

156   Here’s How to Treat Childhood Apraxia of Speech

Phonetic Placement Cues The clinician provides a verbal description of how the specific phonemes are produced. Phonetic placement cues are often combined with gestural cues and other types of cues. Phonetic placement cues are not specific to apraxia treatment but are commonly used in the treatment of articulation disorders. The clinician describes to the child how the speech sound is produced. For example, when producing the /f/ sound, the child can be told to “Bring the lower lip up to meet the top teeth then blow.” The choice of wording of the cues will be dependent on what aspect of the movement the child needs to change. For instance, if a child is working on /s/ production, your phonetic placement cues will be different if the child is substituting /t/ for /s/ than if the child has a lateral lisp. Phonetic placement cues are one of the most commonly used cues in CAS treatment, so becoming adept at explaining movement of the articulators in ways that children can understand is essential for skilled treatment. It is important to talk to the child about jaw height, tongue, and lip positions and movements, and degree of tension or tightness of the oral musculature to help the child be successful in understanding the movement expectations.

Mouth Pictures and Videos Pictures or videos of the mouth can be used to illustrate how specific sounds are produced. There is an abundant number of mouth shape pictures available that illustrate the lip shape, jaw height, and tongue position for vowel and consonant phonemes through online sellers such as Etsy (https://www.etsy.com) and Teachers Pay Teachers (https://www.teacherspayteachers.com). Reading and apraxia materials that provide pictures of mouth shapes associated with specific phonemes include Lindamood Phoneme Sequencing Program for Reading, Spelling, and Speech (Lindamood & Lindamood, 1998), Phonic Faces (Norris, 2003), Say and Do Sound Production Flip Book and Activities for Apraxia and More! (Perkins Faulk & Priddy, 2005). Videos of specific phoneme production can be viewed using the Sounds of Speech application ($3.99) from the University of Iowa Research Foundation. A preview of the application is found at https://apps.apple.com/us/app/sounds-of-speech/id780656219. This application displays a moving schematic of a sagittal section of the head and neck, showing the movements of the articulators and the relationships of the lips, teeth, tongue, pharynx, velum, and vocal folds during production of each phoneme of English. A video showing a frontal view of a person producing each phoneme also can be viewed on the website along with a written description of the place, manner, and voicing required to achieve accurate articulatory production of the phonemes. The Speech Tutor by Synapse Apps LLC ($24.99) and Speech Sounds Visualized by Pullman Regional Hospital (by monthly or annual subscription) are two apps that can be used on a tablet computer to help children visualize movement of the articulators during production of phonemes.

Syllable Pictures Words containing two or more syllables can be simplified for children by using separate pictures that denote the individual syllables of the target word. If a child can recognize and produce the individual syllables of a word as separate words, the production of the whole word often is much easier. Compound words lend themselves well

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   157

to this technique and are the most basic example of using separate pictures to denote a new word. Words such as doghouse, cupcake, or football can be shown as two separate pictures that, when linked together, create a new word. Pictures also can be used to denote syllables of two- and three-syllable words that are not compound words (e.g., movie — a cow for “moo” and the letter V; hamburger — a ham, someone who is cold “brrr,” and a bear “grrr;” circus — a nicely dressed man “sir” and a person giving another a kiss “kiss”). In some cases, not all the syllables need to be drawn, only the ones that are challenging for the child. For example, the medial syllable, “le,” in “elephant,” and the initial syllable, “com,” in “computer,” are weak and, thus, more likely to be omitted. Quickly drawing a person singing for “le” or a person signaling for a dog to “come” may be all that is needed to elicit inclusion of the omitted syllables. Figure 3–4 shows examples of syllable pictures for compound words and 2+ syllable words. Tables 3–20 and 3–21 provide lists of compound words and two- and three-syllable words that may lend themselves to syllable picture cues.

Tactile-Kinesthetic Cues Tactile cues provided by the clinician to facilitate accurate and efficient articulatory movements. When children do not respond to models, phonetic placement cues, or other metacognitive strategies and cues, tactile cues may be beneficial. Tactile cues offer a way to increase the child’s tactile, kinesthetic, and proprioceptive awareness of the movement gestures. Two programs commonly described in CAS treatment literature that incorporate tactile cueing are DTTC (Strand, 2020) and PROMPT (Hayden, 2004). Both programs are described in greater detail in Chapter 4. Placement of your hand or fingers under a child’s chin can support appropriate jaw opening for specific vowels. The fingers can be used to support lip closure for bilabials or lip rounding and retraction for vowels. Be sure to watch yourself in the mirror as you say the words in a natural way to determine the correct jaw height, lip rounding/retraction, or lip tightness/tension for the specific target utterance, as these movements will vary depending on adjacent phonemes. Keep in mind, of course, that the trajectories of jaw movements are wider in younger children than adults.

Fading of Multisensory Cues Although providing cues is essential to improving sensorimotor speech skills, the ultimate goal is to fade cues over time, so the child takes greater responsibility for the clarity of their own speech. Fading cues also reduces the child’s dependence on cues. To help the child take greater responsibility over accurate speech production, the clinician can use the following strategies: • transition from using more salient to less salient cues (e.g., moving from tactile cue to direct model to metaphor) • shift from using multisensory cues to simpler cues (e.g., moving from combined visual, tactile, auditory cues to an auditory cue alone) • gradually fade cues over time (e.g., moving from verbal model to no model) A more detailed discussion of adding and fading of cues is found in the discussion of DTTC in Chapter 4.

158   Here’s How to Treat Childhood Apraxia of Speech

Figure 3–4.  Syllable pictures for compound words and two- to three-syllable words.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   159

Table 3–20.  Compound Words for Syllable Pictures Airplane

Backpack

Baseball

Bathroom

Bedroom

Birdhouse

Cowboy

Cupcake

Downstairs

Flashlight

Football

Haircut

Homework

Inside

Notebook

Outside

Pancake

Ponytail

Popcorn

Raincoat

Sidewalk

Snowman

Something

Suitcase

Toothbrush

Upstairs

Watermelon

Table 3–21.  Two- and Three-Syllable Words for Syllable Pictures Also All sew

Always All ways

Answer Ann sir

Baby bay bee

Baking bay king

Before bee four

Believe bee leave

Body bah D

Candy can D

Careful care full

Christmas Chris miss

DVD DVD

Enjoy in joy

Explain X plane

Friday fry day

Going go wing

Hamburger ham brrr grrr

Hiding hi ding

Label lay bull

Lady lay D

Neighbor neigh brrr

Number numb brrr

Okay OK

Paper pay purr

Pilot pie lit

Purple purr pull

Radio ray D O

Snowing snow wing

Snowy snow whee

Tiny tie knee

Tomato toe may toe

Tomorrow two ma row

Video V D Yo

160   Here’s How to Treat Childhood Apraxia of Speech

Intensity of Services Much of the focus of research in speech-language pathology literature has been on trying to determine if specific treatment methods work. Far less research has focused on determining the amount of treatment required to facilitate improvement. Treatment intensity commonly is conceptualized as the number of treatment minutes per week/month for a given period of time (e.g., 90 min per week for 6 months). The critical elements regarding how many properly administered teaching episodes will be occurring within a session and the quality of the teaching episodes are eliminated from this simplistic model of treatment intensity (Warren et al., 2007). For a broader view of treatment intensity, several clinical questions can be considered including the following: • What is the optimal treatment dose? Dose is defined as “the number of properly administrated teaching episodes during a single intervention session” (Warren et al., 2007, p. 71). A teaching episode is “the sequence of events from initial elicitation of a target through the child’s final attempt before switching to another target” (Maas et al., 2019, p. 3168). For example, a child is working to establish accurate production of the target phrase, “stop it.” During a single teaching episode, the child may practice the target utterance five times before the target is produced correctly and a new teaching episode of “stop it” is begun. Those five production attempts are considered a single teaching episode. Thus, during a session, the number of production attempts will be higher than the number of teaching episodes. • What dose form is being used? Dose form is defined as “the typical task or activity within which the teaching episodes are delivered” (Warren et al., 2007, p. 71). Whereas dose is a quantitative factor, dose form is a qualitative factor in treatment and an extremely important factor in the effectiveness of treatment. What types of tasks and activities you do during intervention are typically based on which intervention program is being used and your underlying theoretical foundations. A more thorough discussion of a variety of evidence-based intervention programs for CAS is found in Chapter 4. In short, it is important to become familiar with a variety of programs so you can choose which program is most appropriate for a given child based on a number of factors (e.g., age, severity, specific challenges). • What is the appropriate dose frequency? Dose frequency is defined as “the number of times a dose of intervention is provided per day and per week” (Warren et al., 2007, p. 72). It encompasses both the number of sessions per week and session duration (e.g., one weekly 30-min session [low intensity] versus four weekly 30-min sessions [high intensity]). Researchers who have made suggestions regarding dose frequency for children with CAS typically recommend between two and four sessions per week with a high frequency of teaching episodes per session (Murray et al., 2015, Namasivayam et al., 2015; Strand, 2020). • What is the anticipated total intervention duration? Total intervention duration is described as “the time period over which a specified intervention is presented” (Warren et al., 2007, p. 71). In treatment studies for children with CAS, the typical treatment duration is a specified number of weeks (e.g., 3, 6, 12 weeks). In reality, however,

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   161

the treatment duration is far greater than the short durations used in research and will vary based on factors including the severity and complexity of the child’s communication challenges, as well as the child’s response to treatment. • What is the most desirable clinician-child ratio? The clinician-child ratio refers to the ratio of the number of clinicians to clients. When a child is seen by the SLP individually, the clinician-client ratio would be 1:1; a dyad would be 1:2; and a small group could be 1:3 or 1:4. Theoretically, a smaller clinician-client ratio, as in individual treatment, would allow for a higher dose of teaching episodes. This would provide greater treatment intensity and would be preferable. There may be factors and situations, however, that would warrant dyad or small-group treatment. These factors may include motivation (a child may be more motivated to practice when working with a peer), individual communication profiles (a child may have needs in the area of social communication that warrant dyad or group treatment to meet social/pragmatic goals), and stage of development (a child may be working on generalization). When you multiply dose by dose frequency by total intervention duration, you arrive at a cumulative intervention intensity (Warren et al., 2007). For example, a child receiving two, 60-min sessions per week with ~50 teaching episodes per session for 50 weeks would have a cumulative intervention intensity of 5,000 teaching episodes over 50 weeks. Table 3–22 provides examples for calculating cumulative intervention intensity.

Making Clinical Decisions About Treatment Intensity Many researchers and experts in motor learning and CAS agree that to improve sensori­ motor planning, intensive treatment is required (Maas et al., 2008; Strand & Skinder, 1999; Table 3–22.  Calculating Cumulative Intervention Intensity Total Intervention Duration

Cumulative Intervention Intensity

Two sessions per week, 50 min each

30 weeks

1,200 teaching episodes

~60 teaching episodes

Three sessions per week, 30 min each

30 weeks

5,400 teaching episodes

PROMPTa

~50 teaching episodes

Two sessions per week, 50 min each

30 weeks

3,000 teaching episodes

ReSTa practice portion

100 teaching episodes

Two sessions per week, 60 min each

10 weeks

2,000 teaching episodes

Treatment Method

Dose

Dose Frequency

Language stimulation

~20 teaching episodes

DTTCa

Note. DTTC, Dynamic Temporal and Tactile Cueing; PROMPT, PROMPTS for Restructuring Oral Muscular Phonetic Targets; ReST, Rapid Syllable Transition Treatment. a These treatment programs are described in greater detail in Chapter 4.

162   Here’s How to Treat Childhood Apraxia of Speech

Strode & Chamberlain, 2006). Strand (2008) recommends short, frequent treatment sessions for children with severe CAS (e.g., three to five 20- to 30-min sessions per week). Namasivayam et al. (2015) found individual motor speech treatment delivered two times per week was more effective in improving the articulation and functional communication of children with CAS than treatment delivered one time per week. Although dose frequency for children with moderate or severe CAS would be high, we may expect an older child with CAS who has made substantial progress in prior treatment and whose speech intelligibility is improving to continue to make progress with lower dose frequency. The critical element of dose cannot be overlooked when making decisions about treatment intensity. You want to be sure you are applying treatment methods that provide ample opportunities for practice to develop strong sensorimotor plans. Clinical decisions about treatment intensity often are made based on factors that are unrelated to the child’s needs, such as length of a class period at school, typical length of a treatment session at the clinic site, or the distance the child needs to travel to attend speech. In fact, decisions about treatment intensity should be more dependent on the child’s developmental profile and individual needs. Things to consider may include the following: • severity of the child’s speech praxis challenges • age of the child • attention capacities of the child • physical stamina of the child • types of goals being addressed in speech and language treatment • coexisting needs that may require other types of treatment (motor, cognitive, learning, medical, social, emotional)

Sample Cases Five different children are described in this section. A summary is provided regarding the speech and language skills and needs of each child. Following the case summary section, a table is provided that compares and contrasts the number of service minutes per week and how those minutes are distributed (e.g., length of sessions, group versus individual) for each child. Child 1 Name:  Jayden Age:  3 years, 7 months Diagnosis:  CAS; expressive language disorder Summary:  Jayden demonstrates specific deficits in speech praxis that severely impact his speech intelligibility. He has a limited phonetic inventory that impacts his expressive communication skills. He is speaking primarily in single words. His expressive vocabulary is quite delayed for his age, though this appears to be linked to his limited phonetic inventory. His receptive language and cognitive skills appear to be on target for his age. He is beginning to display frustration with his challenges in expressing his ideas, leading to frequent temper tantrums at home and occasional noncompliance during the initial evaluation. He is playful, engaging (typically gesturally), and well-liked by his peers in preschool.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   163

Recommendations:  It is recommended that Jayden receive intensive speech and language treatment services to upgrade speech intelligibility and expressive language. Short, frequent treatment sessions are recommended. Child 2 Name:  Kara Age:  6 years, 4 months Diagnosis:  CAS Summary:  Kara has been receiving speech and language treatment services since the age of 2 years, 6 months. At age 3 years, Kara was diagnosed with CAS. She received intensive speech and language treatment, including four 30-min sessions per week in her school district preschool itinerant speech program and two 45-min sessions per week privately. She made excellent progress. Her current goals reflect her need to improve phoneme sequencing for multisyllabic words, increase accuracy of final consonant clusters, and increase consistency of /l/ production at single-word and sentence levels. Recommendations:  It is recommended that Kara receive twice-weekly speech and language treatment services to continue to upgrade speech intelligibility and address residual articulation issues. Child 3 Name:  Mateo Age:  8 years, 8 months Diagnosis:  CAS; receptive and expressive language disorder Summary:  Mateo has been enrolled in speech and language treatment since age 2 years. His initial diagnosis was Developmental Delay. At age 3 years, Mateo entered a special education preschool class and received 90 min per week of speech and language treatment and 60 min per month of occupational therapy. He was diagnosed at age 4 years with severe CAS and began receiving an additional 60 min per week of private treatment to address his speech praxis needs. While he has made good progress, his overall speech intelligibility remains moderately impaired. His current speech goals reflect his need to increase accurate production of fricative phonemes; increase consistency of CVCVC, CVCCVC, CCVC, and CVCVCV syllable shapes; and stabilize the accuracy of phoneme sequences at the phrase and sentence levels. Current receptive language goals reflect Mateo’s need to improve his ability to follow verbal instructions of increasing length and complexity, increase comprehension of conceptual terms, and improve comprehension of higher-level question forms. Expressively, Mateo is working to increase mean length of utterance, increase expressive vocabulary, and improve grammar. Social language goals involve increasing initiation of language with peers and using his language for a wider range of communicative functions. Recommendations:  It is recommended that Mateo receive intensive speech and language treatment services to upgrade speech intelligibility, receptive language, expressive language, and social communication skills. Establishing an alternative means of communication, such as a voice output communication device, should be initiated so Mateo has a way to communicate intelligibly when communicative breakdowns occur or when interacting with unfamiliar listeners.

164   Here’s How to Treat Childhood Apraxia of Speech

Child 4 Name:  Maribella Age:  5 years, 11 months Diagnosis:  Autism spectrum disorder; CAS Summary:  Bella began receiving speech and language therapy at the age of 2 years, 6 months and was diagnosed with autism at age 3 years. Over the past year, Bella has begun to use more verbal language and improve her verbal imitation skills. This recent surge in verbal language allowed for completion of a motor speech evaluation. The recent motor speech assessment confirmed CAS. Because Bella is beginning to demonstrate stronger imitation skills recently, verbal communication will be addressed through individual treatment. However, dyad and small-group treatment will continue to be important to upgrade social pragmatic language skills. Recommendations:  It is recommended that Bella receive intensive speech and language treatment services to facilitate improved speech praxis skills, receptive language, expressive language, and social interaction. Child 5 Name:  Henry Age:  6 years, 2 months Diagnosis:  Dysarthria; CAS; receptive and expressive language disorder Summary:  Henry has been receiving speech and language treatment in addition to other related services (occupational and physical therapy) since approximately 18 months of age. He exhibits a severe speech and language impairment. His combined dysarthria and CAS make his speech attempts highly inconsistent and labored. His phoneme and syllable shape repertoires are quite limited. Manual signs are approximations, as limb apraxia is evident. Recently, his SLP has introduced Picture Exchange Communication System, though he is not using it spontaneously at this time. The school and family are in the process of an augmentative communication evaluation and hope to choose a voice output communication device soon. Henry is enrolled in a self-contained special education classroom and spends the majority of time each school day either in this classroom or with one of his related service providers. He is included in the first-grade general education classroom for selected activities (e.g., calendar time, art, music, special events). Henry continues to receive physical and occupational therapy to address gross and fine motor strength, stability, and coordination issues. Recommendations:  It is recommended that Henry receive intensive, direct speech and language treatment services, plus weekly consultation to help his school staff facilitate improved communication skills aimed at increasing spontaneity, variety of communicative functions, and the expression of a wider range of ideas. Focus of treatment will be to establish a consistent means of functional, multimodal communication. These case examples illustrate the need for flexibility in program planning for children with CAS. Although intensive, individual treatment is a rule of thumb, it is essential to consider multiple factors when making decisions about treatment schedules, as shown in Table 3–23.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   165

Table 3–23.  Intensity and Distribution of Speech and Language Treatment Services for Five Children With CAS Child

Monday

Tuesday

Wednesday

Thursday

Friday

Jayden

30-min 1-to1 to address speech praxis

30-min 1-to1 to address speech praxis

30-min 1-to1 to address speech praxis

Kara

30-min 1-to1 or dyad to address articulation

Mateo

30-min 1-to1 to address speech praxis and use of augmentative and alternative communication (AAC)

30- to 45-min small group or dyad to address language and social interaction

30-min 1-to1 to address speech praxis and use of AAC

30-min 1-to1 to address speech praxis and use of AAC; 30-min consultation to classroom staff to support use of AAC device

30- to 45-min small group or dyad to address language and social interaction

Bella

30-min 1-to1 to address speech praxis

30- to 45-min small group or dyad to address language and social interaction

30-min 1-to1 to address speech praxis

30- to 45-min small group or dyad to address language and social interaction

30- to 45-min small group or dyad to address language and social interaction

Henry

30-min 1-to1 or dyad to address functional, multimodal communication

30-min 1-to1 or dyad to address functional, multimodal communication (co-treatment with occupational therapist)

30-min 1-to1 or dyad to address functional, multimodal communication

30-min consultation with classroom staff to support use of AAC

30-min dyad to address use of newly acquired skills with a peer

30-min 1-to1 or dyad to address articulation

Putting It All Together The final section of this chapter is a discussion of ways in which SLPs can integrate the information from earlier sections of this chapter. We refine our clinical skills by making thoughtful decisions during planning and treatment to increase effectiveness in facilitating initial acquisition of skills, as well as retention and transfer. There are many things to consider simultaneously related to conditions of practice, conditions of feedback, treatment

166   Here’s How to Treat Childhood Apraxia of Speech

context, and complexity of the task to be sure we are providing services that are effective and efficient. Rvachew and Brosseau-Lapré (2012) describe the importance of working at the child’s optimum challenge point, a concept earlier described by Guadagnoli and Lee (2004). It is the point where the task is neither too difficult nor too easy for the child and is a moving target from moment to moment in treatment. There are a range of variables that come into play to facilitate working at the child’s optimum challenge point. As clinical skills become more refined, the SLP is able to manipulate these variables in real time to keep the child working at the optimum challenge point. At any point within a session, the clinician can vary the following: • complexity/difficulty of the task • level of cueing • amount and type of feedback • treatment context When a child is struggling to maintain a relatively high level of accuracy, the clinician will make the task easier, provide more cues, provide more frequent and descriptive feedback, and/or maintain a familiar treatment context. Likewise, when the child is performing at a very high level of accuracy, the clinician can increase the level of task difficulty, provide fewer cues, offer less frequent and less descriptive feedback, and/or vary the context of treatment. Table 3–24 lists several variables that can be adjusted by the SLP in real time to keep the child working at an optimum challenge point and get the most out of treatment. By manipulating one or more of these variables from moment to moment within the treatment session, the clinician is able to facilitate higher levels of skill acquisition and help the child attain better retention and transfer of skills acquired in therapy. Ideally, the clinician is providing the most appropriate intensity of service, planning the sessions carefully, and then manipulating these variables in “real time” to provide the best quality service possible for the child.

Table 3–24.  Modifying Variables in Treatment to Achieve Optimum Challenge Point How to Reduce Level of Challenge

Variable

How to Increase Level of Challenge

Choose a target with a less complex syllable shape, e.g., instead of “mom,” try “ma.”

Syllable shape complexity

Choose a target with a more complex syllable shape, e.g., instead of “ma” try “mommy” or “mom.”

Choose target phonemes that are less challenging, e.g., instead of fricative, try a stop, nasal, or glide.

Phonemic complexity

Choose target phonemes that are more challenging, e.g., instead of a stop, try a fricative.

Reduce the diversity of phonetic contexts, e.g., instead of “bye dad,” try “bye bye.”

Phonetic contexts

Increase the complexity of phonetic contexts by manipulating the number of variations in place, manner, and voicing within the same utterance, e.g., instead of pop up, try hop down.

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   167

Table 3–24.  continued How to Reduce Level of Challenge

Variable

How to Increase Level of Challenge

Decrease rate of production of target utterance.

Rate of production

Increase rate of production of target utterance.

Decrease length of utterance, e.g., instead of “I want more pizza,” try “I want pizza” or “more pizza.”

Utterance length

Increase length of utterance, e.g., instead of “I want more pizza” try “I want more pepperoni pizza, please.”

Reduce grammatical complexity, e.g., Instead of “Do you like cookies?” try “I like cookies.”

Grammatical complexity

Increase grammatical complexity, e.g., instead of “I want pizza,” try “Do you want pizza?” or “Mommy wants pizza.”

Provide more salient cues, e.g., instead of a direct model, use simultaneous production and a tactile cue.

Cueing

Provide less salient cues, e.g., instead of a direct model, use a gestural cue or a metaphor. Fade cues and move toward elicited productions, e.g., production of the target utterance in response to a question or a fill-in-the-blank sentence.

Increase frequency of feedback.

Feedback frequency

Reduce frequency of feedback.

Instead of knowledge of results, provide more specific feedback in the form of knowledge of performance.

Type of feedback

Instead of knowledge of performance, provide less specific feedback in the form of knowledge of results.

Move from less structured to more structured activities, e.g., practice the targets in a simple, structured game.

Level of structure

Move from structured to less structured activities, e.g., try eliciting target utterances in a play activity.

Provide practice opportunities in a familiar setting, e.g., treatment room, “work-area” in the child’s home.

Setting

Provide practice opportunities in less familiar or less structured settings, e.g., classroom, hallway, playground.

Reduce environmental distractions, e.g., competing visual and auditory noise.

Distractions

Increase distraction during practice, e.g., practice while tossing a ball back and forth or building a block tower.

Practice with the primary therapist or other familiar practice partner or caregiver.

Communication partners

Provide opportunities to practice with less familiar partners, e.g., a different therapist, a peer, a less familiar person in the school or clinic, a person in the community.

168   Here’s How to Treat Childhood Apraxia of Speech

References Allen, M. M. (2013). Intervention efficacy and intensity for children with speech sound disorder. Journal of Speech, Language, and Hearing Research, 56, 865–877. https://doi.org/10.1044/1092-4388(2012/11-0076) American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical report]. Available from www.asha.org/policy/ Bleile, K. (2006). The late eight. Plural Publishing. Brown, R. (1973). A first language: The early stages. Harvard University Press. Burningham, J. (1971). Mr. Gumpy’s outing. Henry Holt Publishing. Chappell, G. E. (1973). Childhood verbal apraxia and its treatment. Journal of Speech and Hearing Disorders, 38, 362–368. https://doi.org/10.1044/jshd.3803.362 Davis, B. L., & MacNeilage, P. F. (1990). Acquisition of correct vowel production: A quantitative case study. Journal of Speech and Hearing Research, 33, 16–27. https://doi.org/10.1044/jshr.3301.16 Davis, B. L., & MacNeilage, P. F. (1995). The articulatory basis of babbling. Journal of Speech and Hearing Research, 38, 1199–1211. https://doi.org/10.1044/js​ hr.3806.1199 Davis, B. L., & Velleman, S. L. (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers. Infant-Toddler Intervention: The Transdisciplinary Journal, 10, 177–192. Edeal, D. M., & Gildersleeve-Neumann, C. E. (2011). The importance of production frequency in therapy for childhood apraxia of speech. American Journal of Speech-Language Pathology, 20, 95–110. https://doi​ .org/10.1044/1058-0360(2011/09-0005) Guadagnoli, M. A., & Lee, T. D. (2004). Challenge point: A framework for conceptualizing the effects of various practice conditions in motor learning. Journal of Motor Behavior, 36, 212–224. https://doi.org/10.3200/ JMBR.36.2.212-224 Hayden, D. A. (2004). P.R.O.M.P.T. Prompts for restructuring oral muscular phonetic targets, introduction to technique: A manual. PROMPT Institute. Iuzzini-Seigel, J., Hogan, T. P., Guarino, A. J., & Green, J. R. (2015). Reliance on auditory feedback in children with childhood apraxia of speech. Journal of Communication Disorders, 54, 32–42. https://doi.org/​ 10.1016/j.jcomdis.2015.01.002 Kehoe, M. M., & Stoel-Gammon, C. (2001). Development of syllable structure in English speaking children with particular reference to rhymes. Journal of Child Language, 28, 393–432. https://doi.org/10.1017/ S030500090100469X

Ladefoged, P. (2001). A course in phonetics (4th ed.). Harcourt. Lindamood, P. C., & Lindamood, P. D. (1998). The Linda­ mood Phoneme Sequencing Program for Reading, Spelling, and Speech. Pro-Ed. Maas, E., Butalla, C. E., & Farinella, K. A. (2012). Feedback frequency in treatment for childhood apraxia of speech. American Journal of Speech-Language Pathology, 21, 239–257. https://doi.org/10.1044/10580360(2012/11-0119) Maas, E., & Farinella, K. A. (2012). Random versus blocked practice in treatment of childhood apraxia of speech. Journal of Speech, Language, and Hearing Research, 55, 561–578. https://doi.org/10.1044/10924388(2011/11-0120) Maas, E., Gildersleeve-Neumann, C., Jakielski, K., Kovacs, N., Stoeckel, R., Vradelis, H., & Welsh, M. (2019). Bang for your buck: A single-case experimental design study of practice amount and distribution in treatment for childhood apraxia of speech. Journal of Speech, Language, and Hearing Research, 62, 3160–3182. https:// doi.org/10.1044/2019_JSLHR-​S-​18-0212 Maas, E., Robin, D., Austermann Hula, S., Freedman, S., Wulf, G., Ballard, K., & Schmidt, R. (2008). Principles of motor learning in treatment of motor speech disorders. American Journal of Speech-Language Pathology, 17, 277–298. https://doi.org/10.1044/1058-0360​ (2008/025) Marshalla, P. (2009a). Pam’s place cues for consonants. https://www.youtube.com/watch?v=lBclowP9uds Marshalla, P. (2009b). Pam’s place cues for vowels. https://www.youtube.com/watch?v=lBclowP9uds McCormick, L., & Schiefelbusch, R. (1984). Early language intervention. Charles E. Merrill. Murray, E., McCabe, P., & Ballard, K. J. (2012). A comparison of two treatments for childhood apraxia of speech: Methods and treatment protocol for a parallel group randomised control trial. BMC Pediatrics, 12. https://doi.org/10.1186/1471-2431-12-112 Murray, E., McCabe, P., & Ballard, K. J. (2015). A randomized controlled trial for children with childhood apraxia of speech comparing Rapid Syllable Transition Treatment and the Nuffield Dyspraxia Programme (3rd ed.). Journal of Speech, Language, and Hearing Research, 58(3), 669–686. https://doi.org/​10​ .1044/2015_ JSLHR-S-13-0179 Namasivayam, A. K., Pukonen, M., Goshulak, D., Hard, J., Rudzicz, F., Rietveld, T., . . . Van Lieshout, P. H. H. M. (2015). Treatment intensity and childhood apraxia of speech. International Journal of Language

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   169 & Communication Disorders, 50(4), 529–546. https:// doi.org/10.1111/1460-6984.12154 Nelson, K. (1973). Structure and strategy in learning to talk. Monographs of the Society for Research in Child Development, 38, 1–135; cited by McCormick & Schie­ felbusch (1984). Norris, J. (2003). Phonic faces manual (2nd ed.). Baton Rouge, LA: Elementory LC. https://www.elementory​ .com/info.html Perkins Faulk, J., & Priddy, L. (2005). Say and do sound production flip book and activities for apraxia and more! Super Duper Publications. Preston, J. L., Leece, M. C., & Storto, J. (2019). Tutorial: Speech motor chaining treatment for schoolage children with speech sound disorders. Language, Speech, and Hearing Services in Schools, 50, 343–355. https://doi.org/10.1044/2018_LSHSS-18-0081 Rvachew, S., & Brosseau-Lapré, F. (2012). Developmental phonological disorders: Foundations of clinical practice. San Diego, CA: Plural Publishing. Rice, M., Sell, M., & Hadley, P. (1991). Social interactions of speech and language-impaired children. Journal of Speech and Hearing Research, 34, 1299– 1307. https://doi.org/10.1044/jshr.3406.1299 Schmidt, R. A., & Lee, T. D. (2005). Motor control and learning: A behavioral emphasis (4th ed.). Human Kinetics. Strand, E. A. (2008, July). Principles of speech motor learning [Paper presentation]. Childhood Apraxia of Speech Association of North America (CASANA) 2008 National Conference on Childhood Apraxia of Speech, Williamsburg, VA, United States. Strand, E. A. (2020). Dynamic temporal and tactile cueing: A treatment strategy for childhood apraxia of speech. American Journal of Speech-Language Pathology, 29, 30–48. https://doi.org/10.1044/​2019​_AJ​ SLP-19-0005 Strand, E. A., & Skinder, A. (1999). Treatment of developmental apraxia of speech: Integral stimulation

methods. In A. J. Caruso & E. A. Strand (Eds.), Clinical management of motor speech disorders in children (pp. 109–148). Thieme. Strode, R., & Chamberlain, C. (2006). The source for childhood apraxia of speech. LinguiSystems. Terband, H., Maassen, B., Guenther, F. H., & Brumberg, J. (2009). Computational neural modeling of speech motor control in childhood apraxia of speech (CAS). Journal of Speech, Language, and Hearing Research, 52, 1595–1609. https://doi.org/10.1044/1092-4388​(2009/​ 07-0283) Thomas, D. C., McCabe, P., & Ballard, K. J. (2014). Rapid syllable transitions (ReST) treatment for childhood apraxia of speech: The effect of lower-dose frequency. Journal of Communication Disorders, 51, 29–42. https:// doi.org/10.1016/j.jcomdis.2014.06.004 Vail, P. L. (1993). Emotion: The on off switch for learning. Modern Learning Press. Velleman, S. L. (2002). Phonotactic therapy. Seminars in Speech and Language, 23(1), 43–56. Velleman, S. L. (2003). Childhood apraxia of speech resource guide. Thomson Delmar Learning. Warren, S. F., Fey, M. E., & Yoder, P. J. (2007). Differential treatment intensity research: A missing link to creating optimally effective communication interventions. Mental Retardation and Developmental Disabilities Research Reviews, 13, 70–77. https://doi.org/​ 10.1002/mrdd.20139 World Health Organization. (2007). International classification of functioning, disability and health, children and youth version. http://www.who.int/classifications/ icf/en/ Zuk, J., Iuzzini-Seigel, J., Cabbage, K., Green, J. R., & Hogan, T. P. (2018). Poor speech perception is not a core deficit of childhood apraxia of speech: Preliminary findings. Journal of Speech, Language, and Hearing Research, 61, 583–592. https://doi.org/10.1044/​ 2017_JSLHR-S-16-0106

170   Here’s How to Treat Childhood Apraxia of Speech

APPENDIX 3–A

Communicative Functions and Corresponding Target Utterances Worksheet Communicative Function Greeting/closing Requesting objects Requesting actions Requesting attention Rejecting Asking for information Requesting assistance Asking permission Disagreeing Protesting Sharing information Commenting Responding to questions Self-advocacy

Targets to Elicit Communicative Function

3.  Fundamentals of Treatment for Childhood Apraxia of Speech   171

Target Utterance Selection Considerations Worksheet TARGET UTTERANCE SELECTION CONSIDERATIONS WORKSHEET Name: Date:                 Age: Speech Language Environmental Interests Social

Intervention Plan Worksheet Sample Form Intervention Plan Worksheet Name: Date: Word Shape(s)

Social/Pragmatic Goals

Phoneme(s) C and V

Materials

Activities

Vocabulary; Phrase Structures

CHAPTER

4

Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech

W

hen making decisions about the most appropriate treatment programs for our clients, we look for evidence to help guide our treatment decision-making process. Figure 4–1 illustrates an evidence-based triangle that is commonly referred to in evidence-based practice (EBP), along with the more recent evidence-based diamond model (Higginbotham & Satchidanand, 2019). Evidence-informed decision-making (EIDM) incorporates internal evidence into the decision-making process. Higginbotham and Satchidanand recommend considering these four components of EBP when making decisions about treatment: (a) external evidence (best available evidence from scientific literature); (b) clinical expertise and expert opinion; (c) client/caregiver perspectives and preferences based on cultural circumstances, priorities, and values; and (d) internal evidence (data collected by the treating clinician). Looking at internal evidence is a relatively new, but critical, perspective in discussions of EIDM. Olswang and Bain (1994) suggest that careful data-keeping and analysis is an essential component of EIDM and that the clinician should consider the following when reviewing the data: • if the client is responding to the treatment program • if significant change is occurring • if the treatment is responsible for the change • how long specific therapy targets should be treated

There are a variety of ways to collect and analyze data depending on the child’s goals. A more detailed discussion of data-keeping in treatment of childhood apraxia of speech (CAS) can be found in Chapter 12.

173

174   Here’s How to Treat Childhood Apraxia of Speech

A

B

Figure 4–1.  A. Evidence-based practice triangle model. B. Evidence-based practice diamond model. (Adapted from “From triangle to diamond: Recognizing and using data to inform our evidence-based practice,” by J. Higginbotham and A. Satchidanand, ASHA Journals Academy, April 2019. Used with permission from Jeff Higginbotham.)

As more research in CAS treatment becomes available, the review of external evidence should be given substantial consideration when making treatment decisions. When analyzing external evidence, you will want to determine the level of evidence available for various treatment approaches you are considering. Table 4–1 provides a summary of levels of evidence for different types of research designs, with systematic reviews/meta-analysis of multiple randomized control trial (RCT) studies having the strongest evidence and expert opinion without research justification having the weakest evidence. Within those studies, even in RCTs, other factors such as number of participants, bias, and the criteria used to choose the participants need to be taken into consideration when determining the strength of the research. For each level of evidence, one example from peer-reviewed journals is listed. Because children with CAS have difficulty with sensorimotor planning and programming, most treatment programs designed for children with CAS are sensorimotor-based treatment programs that incorporate at least some of the principles of motor learning described in Chapter 3 and emphasize some of these common features, including the following: • providing frequent and intensive practice, particularly for children with moderate-tosevere CAS • focusing on addressing sensorimotor planning and programming • focusing on movement sequences, not individual phonemes, by addressing coarticulation in simple (e.g., CV, VC) to gradually more complex (e.g., CCVC, CVCVC) syllable shapes • shaping those movement sequences into the most accurate productions possible • building an expanding list of functional words and phrases • gradually helping the child develop a complete repertoire of consonants and vowels

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   175

Table 4–1.  Levels of Research Evidence Level of Evidence

Description

Example in CAS Literature

1a

Meta-analysis of >1 randomized control trials

None available

1b

Single randomized control trial

Murray, E., McCabe, P., & Ballard, K. J. (2015). A randomized controlled trial for children with childhood apraxia of speech comparing Rapid Syllable Transition Treatment and the Nuffield Dyspraxia Programme (3rd ed.). Journal of Speech, Language, and Hearing Research. https://doi.org/10.1044/2015_JSLHR-S-13-0179

2

Well-designed control studies without randomization (e.g., case control or cohort study, single-case experimental design, quasiexperimental study)

McNeill, B. C., Gillon, G. T., & Dodd. B. (2009). Effectiveness of an integrated phonological awareness approach for children with childhood apraxia of speech (CAS). Child Language Teaching and Therapy, 25, 341– 366. https://doi.org/10.1177/0265659009339823

3

Case reports, correlational

Lundeborg, I, & McAllister, A. (2007). Treatment with a combination of intraoral sensory stimulation and electropalatography in a child with severe developmental dyspraxia. Logopedics Phoniatrics Vocology, 32, 71–79. https://doi.org/10.1080/14015430600852035

4

Opinion of respected authorities, expert committee reports

American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical report]. https:// www.asha.org/policy/.

Note.  Adapted from Key steps in infusing evidence into CE course content: Step 2, by American Speech-LanguageHearing Association, n.d., https://www.asha.org/ce/for-providers/ebcestep2/; EBP and speech sound disorders: An anthology of 120 peer reviewed studies of phonological intervention 1978–2008 [Paper presentation], by E. Baker and S. McLeod, November 2008, American Speech-Language-Hearing Association Convention, Chicago, IL, United States; “Introduction,” by A. L. Williams, S. McLeod, and R. J. McCauley, 2021, in Interventions for speech sound disorders in children, by A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), pp. 1–22, ). Copyright 2021 by Paul H. Brookes.

• providing multisensory cues for early success and fading these cues over time • addressing prosody • monitoring and treating the child’s other communication needs (e.g., receptive and expressive language, social language, phonological awareness, fluency) Some of the programs described in this chapter are more appropriate for younger children or children at the earlier stages of motor speech development, while other programs are more appropriate for older children who are working to refine their speech or acquire later-developing phonemes. It is important to keep in mind that no program is meant to be a “one-size-fits-all” program to use with all children with a CAS diagnosis. Rather, treatment decisions should be based on several factors, including the following:

176   Here’s How to Treat Childhood Apraxia of Speech

• the individual child’s profile across a variety of parameters (cognitive, linguistic, motor, social, emotional, attentional) • the specific needs of the child • the child’s specific goals • the child’s changing needs over time • the child’s ability to tolerate more structured or drill-based treatment programs By becoming familiar with a variety of evidence-based treatment programs, as well as the strength of the evidence that supports these programs, the clinician can begin to consider the current needs of each individual child and use the programs and strategies that best match the needs of the child at that point in time. A survey of clinicians who self-identified as having expertise in working with children with CAS found that many clinicians were unfamiliar with approaches for which there was strong supporting research evidence, such as Dynamic Temporal and Tactile Cueing (DTTC; Randazzo, 2019). In addition, some treatments for which there is no research evidence in CAS treatment were commonly used by many speech-language pathologists (SLPs) (e.g., nonspeech oral motor exercises; NSOMEs). These survey results reinforce the need for SLPs to become more familiar with the research evidence supporting treatment of CAS. The process illustrated in Figure 4–2 can help provide guidance when you are determining what treatment program or evaluation method would be most effective for your clients. Rather

Figure 4–2.  Evidence-informed decision-making process.

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   177

than fitting each child with a CAS diagnosis into a particular program, you can consider a child’s specific profile and make an informed decision by critically evaluating the evidence that is most relevant for that child, applying the evidence, then evaluating the outcomes based on data collection. The cyclical process suggests that with each client, you may be posing the same or new questions again during the process of treatment depending on the child’s response to treatment and/or new challenges that need to be addressed. Several programs that offer research evidence to support their effectiveness are described in the next sections of this chapter. References are provided for each of the programs at the end of the chapter, so clinicians may read more detailed information about how to implement each of these programs. The programs described are listed in order of developmental appropriateness. That is, those programs appropriate for younger children or children with more limited speech are listed first, and those appropriate for children at later stages of speech and language development are listed later in the chapter. In addition, some programs that have preliminary evidence regarding their effectiveness in CAS treatment are listed toward the end of the chapter.

Prompts for Restructuring Oral Muscular Phonetic Targets Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT) is a tactually grounded, sensorimotor, cognitive-linguistic intervention model grounded in Dynamic Systems theory, for the treatment of children (6 months and above) and adults with speech sound disorders. PROMPT, developed by Deborah Hayden (Chumpelik, 1984), is a motor-based approach that emphasizes the importance of focusing on functional language within the context of social interaction (Hayden, 2004a, 2004b). Therefore, target utterances would match or slightly exceed the child’s motor, linguistic, cognitive, and social level of functioning (Hayden, 2006). PROMPT assessment and treatment is unique among motor speech treatment approaches in that it requires the treating clinician to assess and treat the child across the physical-sensory, cognitive-linguistic, and social-emotional domains. Thus, target utterances and intervention activities would strive to balance and support (to the highest level possible for that child) the child’s motor speech, cognitive-linguistic, and social-emotional levels of functioning. In addition, intervention activities would be functional and promote turn-taking and social interaction. The theoretical underpinnings of PROMPT align nicely with the World Health Organization’s International Classification of Functioning, Disability, and Health: Children and Youth Version (ICF-CY) Activities and Participation component (World Health Organization, 2007). During evaluation of the physical-sensory domain of the motor speech system, the PROMPT-trained clinician assesses the movements of the speech articulators and determines the coordination of these movements within speech synergies (i.e., jaw-lip, lip, tongue-jaw, tongue-lip, etc.). The Motor Speech Hierarchy (MSH; Figure 4–3) illustrates the sequential development of functional synergies of the motor speech subsystems, including breath support, control of phonation, mandible, lips, tongue, sequenced movements, and prosody. Further, the type and level of tactile/kinesthetic/proprioceptive (TKP) input required to facilitate flexible and refined development of speech motor control is determined. Evaluation and observation of the client’s cognitive-linguistic skills and social/emotional skills provide further information that will influence the treatment goals and intervention activities.

178   Here’s How to Treat Childhood Apraxia of Speech

Figure 4–3.  PROMPT Motor Speech Hierarchy. (Copyright 1994 by the PROMPT Institute. All rights reserved.)

To support motor speech development, the PROMPT-trained clinician provides “dynamic” TKP input to the mandibular-labial-facial-lingual subsystems (e.g., phonation, mandible, labial-facial, lingual). The TKP is delivered to develop and refine functional speech synergies for the stable and intelligible production of phonemes, words, and phrases. Tactile prompts are provided externally to

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   179

• the jaw (to facilitate the accurate degree of jaw opening, provide jaw stability, and reduce extraneous jaw excursions) • the muscles of the face, including the cheeks and lips (to facilitate independent lip closure, rounding, and retraction) • the tissue under the chin (mylohyoid) to facilitate placement, width, and timing of contraction in the tongue musculature) • the throat to indicate and facilitate voicing • the side of the nostril to indicate nasality for /m, n, ŋ/ Prompts are faded as the child develops greater control over the planning and execution of speech movements and coarticulation. The TKP prompts used by a PROMPT-trained clinician are designed to support the following skills: • stabilization of the motor system by always providing support to the head and providing support to the trunk and jaw when necessary • mobilization of the motor system to facilitate articulatory movements and separation of jaw movement from tongue movement and jaw movement from lip movement • utilization of appropriate muscle movements by providing sensory input to the articulatory muscles for accurate placement, timing, and coarticulation • reduction or inhibition of ineffective movements to limit overretraction or overprotrusion of the lips and overextension of the jaw (Hayden, 2008) The PROMPT Institute has created some online story-based materials that can be purchased through Boom Learning. Each story contains target utterances designed to facilitate development at different stages on the MSH. For example, at Stage III, the focus would be on mandibular control in the vertical plane. Target utterances may include hop, hop on, on top, help mom, all done, papa, apple up. At Stage IV, the focus would be on labial/facial control with target utterances such as Oh no, Bo, Bo knows, uh oh, Mimi, you ate, eat food, feed me. Several studies have examined the effectiveness of PROMPT in children and adults with a variety of speech sound disorders. Two studies specifically examine the effectiveness of PROMPT in children with CAS. Dale and Hayden (2013) examined the efficacy of PROMPT in four children with CAS. The study examined the effectiveness of PROMPT overall and also compared the effectiveness of PROMPT when TKP cues were used versus when TKP cues were not used as part of PROMPT. The findings suggest that PROMPT was effective in improving production of trained and untrained targets and in facilitating greater speech intelligibility in children with CAS. Modest evidence was established that TKP cues add to the effectiveness of PROMPT in children with CAS. In another study, Kadis et al. (2014), used magnetic resonance imaging to examine cortical effects of PROMPT treatment in children with CAS. They found that eight of nine children receiving PROMPT intervention exhibited thinning of the left posterior superior temporal gyrus (Wernicke’s area) following PROMPT treatment. PROMPT also has been effective in treatment of children with other types of speech sound disorders, including a recent RCT study showing that 10 weeks of twiceweekly “PROMPT intervention was associated with notable improvements in speech motor

180   Here’s How to Treat Childhood Apraxia of Speech

control, speech articulation, and word-level speech intelligibility” (Namasivayam et al., 2021, p. 613) but not on sentence-level speech intelligibility or functional communication for children with motor speech delay. The URL to the PROMPT website, where you can find more information about PROMPT, including available workshops, is listed in Table 4–4 (later in this chapter).

Nuffield Centre Dyspraxia Programme 3rd Edition (NDP3) The Nuffield Centre Dyspraxia Programme 3rd Edition: NDP3 (Williams & Stephens, 2004) is a program designed to address the motor planning and programming challenges of children ages 3–7 years with CAS who exhibit a wide range of levels of severity. It can be adapted to children younger than 3 years and older than 7 years. NDP3 is a “bottom-up” approach to treatment that begins by helping children establish accurate motor programs for individual vowel and consonant phonemes and then systematically build from simple to increasingly complex syllable shapes, phrases, sentences, and connected speech. An integral feature of the NDP3 approach is the pictorial resources that accompany the treatment hierarchy. Throughout the program hierarchy, children are provided with pictorial and other specific cues and feedback to support the attainment of a full phoneme repertoire and increasingly complex phonotactic structures. The picture resources facilitate the child’s ability to “lay down accurate phonological representations, which in turn support the development of accurate motor programs” (P. Williams, personal communication, April 2, 2015). The program supports the following skills: • expansion of a child’s phonetic inventory • coordination of the connection of consonants and vowels into accurate CV and VC syllables (e.g., /aʊ/ + /t/ = out; /b/ + /i/ = bee) and increasingly complex syllable shapes (e.g., /s/ + wing = wing; /g/ + round = ground) • gradually working to join syllables to form multisyllable words — blending worksheets are provided to facilitate transitioning between sounds and syllables using pictures to represent each unit (e.g., tie + knee = tiny; bay + bee = baby) • facilitation of accurate syllable stress once bisyllable and multisyllable words are introduced • development of phonological awareness skills to address blending and segmentation of syllables and phonemes An important conceptual underpinning of NDP3 is the provision of frequent practice opportunities to support the development of accurate motor programs. The worksheets encourage repetitive practice at all levels. Although the program is built on a hierarchical framework that could be conceptualized as a “brick wall” (as illustrated in Figure 4–4), in which individual phonemes form the base and increasingly complex sequences are built on each subsequent layer, NDP3 also allows for, and encourages working at, more than one level within the same session. For example, a child may be working on (a) establishing accurate production of /ʃ/ in isolation, (b) incorporating well-established CVCV words in simple carrier phrases, and (c) producing voiceless plosives in final positions of CVC words in separate activities within a single session.

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   181

Figure 4–4.  NDP3 hierarchy. (From Nuffield Centre Dyspraxia Programme [3rd ed.], by P. Williams and H. Stephens, 2004. Reproduced with permission from NDP3, the third edition of the Nuffield Centre Dyspraxia Programme.)

Phonological awareness skills are incorporated naturally throughout the stages of the program by including activities to address blending of syllables and phonemes, segmentation of syllables in CVCV and multisyllabic words, and segmentation of individual phonemes at the CVC level. Input training activities also can be incorporated into the program for children who struggle with auditory discrimination. The RCT conducted by Murray et al. (2015) provides evidence that NDP3 is an effective program for facilitating articulatory accuracy, consistency, smooth articulatory transitions, and syllable stress assignment in children with CAS. A more recent RTC (McKechnie et al., 2020) looked at the impact of NDP3 treatment when provided using an Android tablet (rather than using the worksheets and picture cards from the program) under two conditions. In both conditions, children received four weekly, face-to-face sessions for 3 weeks. In the first condition, high-frequency knowledge of performance (KP) and knowledge of results (KR) feedback was provided during each session. In the second condition, high-frequency KP and KR feedback was provided one session per week, and only high-frequency KR feedback was provided during the other three sessions each week to simulate a dosage of one weekly session per week and three at-home practice sessions using a tablet-based treatment protocol. Both groups in the study demonstrated significant improvement in speech outcomes 4 months posttreatment, providing additional, preliminary evidence of the effectiveness of NDP3 in children with CAS. Sample worksheets are shown in Figures 4–5 through 4–10. Additional sample picture cards (which are brightly colored in the NDP3 program’s materials) are shown in Figures 4–11 through 4–13. The URL to the NDP3 website, where you can find more information about NDP3, including available workshops and materials, is listed in Table 4–4.

182   Here’s How to Treat Childhood Apraxia of Speech

Figure 4–5. NDP3 sample VC worksheet. (From Nuffield Centre Dyspraxia Programme [3rd ed.], by P. Williams and H. Stephens, 2004. Reproduced with permission from NDP3, the third edition of the Nuffield Centre Dyspraxia Programme.)

Figure 4–6.  NDP3 sample CVCV worksheet. (From Nuffield Centre Dyspraxia Programme [3rd ed.], by P. Williams and H. Stephens, 2004. Reproduced with permission from NDP3, the third edition of the Nuffield Centre Dyspraxia Programme.)

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   183

Figure 4–7.  NDP3 sample CV-CVC sequencing worksheet. (From Nuffield Centre Dyspraxia Programme [3rd ed.], by P. Williams and H. Stephens, 2004. Reproduced with permission from NDP3, the third edition of the Nuffield Centre Dyspraxia Programme.)

Figure 4–8.  NDP3 sample transition C+CVC=CCVC. (From Nuffield Centre Dyspraxia Programme [3rd ed.], by P. Williams and H. Stephens, 2004. Reproduced with permission from NDP3, the third edition of the Nuffield Centre Dyspraxia Programme.)

184   Here’s How to Treat Childhood Apraxia of Speech

Figure 4–9.  NDP3 sample CV-CV clauses worksheet. (From Nuffield Centre Dyspraxia Programme [3rd ed.], by P. Williams and H. Stephens, 2004. Reproduced with permission from NDP3, the third edition of the Nuffield Centre Dyspraxia Programme.)

Figure 4–10.  NDP3 sample complex sentences worksheet. (From Nuffield Centre Dyspraxia Programme [3rd ed.], by P. Williams and H. Stephens, 2004. Reproduced with permission from NDP3, the third edition of the Nuffield Centre Dyspraxia Programme.)

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   185

Figure 4–11.  NDP3 “moo” picture card. (From Nuffield Centre Dyspraxia Programme [3rd ed.], by P. Williams and H. Stephens, 2004. Reproduced with permission from NDP3, the third edition of the Nuffield Centre Dyspraxia Programme.)

Figure 4–12.  NDP3 “bubble” picture card. (From Nuffield Centre Dyspraxia Programme [3rd ed.], by P. Williams and H. Stephens, 2004. Reproduced with permission from NDP3, the third edition of the Nuffield Centre Dyspraxia Programme.)

Figure 4–13.  NDP3 “computer” picture card. (From Nuffield Centre Dyspraxia Programme [3rd ed.], by P. Williams and H. Stephens, 2004. Reproduced with permission from NDP3, the third edition of the Nuffield Centre Dyspraxia Programme.)

Dynamic Temporal and Tactile Cueing DTTC was developed by Edythe Strand and first described by Strand and Skinder (1999) as a form of integral stimulation (Rosenbek, 1985; Rosenbek et al., 1973). This integral stimulation approach was adapted by Strand for use with children with CAS. Children as young as 2 or 3 years of age may be appropriate candidates for DTTC, as long as they exhibit an intent to communicate and are able to attend to the clinician’s face and to the task for short periods of time. According to Strand (2020), DTTC is intended for “children with more severe CAS and is not intended for long-term use” (p. 33). For children with severe CAS, the intended dosage for DTTC is at least three to four sessions per week. DTTC is based on the assumption that the primary impairment in children with CAS is difficulty with planning and programming movement gestures for speech (Caruso & Strand, 1999; Davis et al., 1998): that is, they have difficulty with accurate coordination of articulatory movements to allow for a continuous flow of movement from one phoneme to another during production of an utterance. Strand (2020) describes several core elements of DTTC: • focusing on coarticulation of speech movements rather than focusing on individual phonemes • helping the child develop a focus and intention to improve movement accuracy • increasing proprioceptive awareness by maximizing proprioceptive input • maximizing the number of practice trials of the target utterances during the session

186   Here’s How to Treat Childhood Apraxia of Speech

• choosing carefully selected, meaningful, and functional utterances to practice during the sessions • using auditory and visual modeling to facilitate imitation • providing additional cues and strategies as needed (e.g., reducing rate of production, using simultaneous production, providing clear and specific feedback, gradually lengthening the time between the clinician’s model and the child’s production) in a dynamic manner to facilitate accurate productions at a normal rate and with varied prosody • gradually fading cueing to facilitate greater independence in production of speech When utilizing the DTTC approach, the following sequence is recommended: 1. Initially, the child produces an utterance immediately following the clinician’s model while watching the clinician (direct imitation). 2. If the child is inaccurate, slow, or clumsy in production of the target, the clinician will produce the utterance with the client (simultaneous production), modeling the target utterance at a reduced rate (rate variations). Additional cues may be added as needed, such as a tactile cue or a phonetic placement cue, to support accurate production of the target utterance. As the child develops greater accuracy and maintains that accuracy at a normal rate and with varied prosody, the clinician begins to fade the cues and returns to direct imitation. 3. When the child can produce the utterance correctly (again, at normal rate and with varied prosody), the clinician slowly begins to increase the temporal interval between the model and the child’s production (delayed imitation) of the target until the child can achieve accurate production of the target without a model. Figure 4–14 illustrates the sequence and dynamic nature of DTTC treatment beginning with Direct Imitation and transitioning to either Delayed Imitation (if the child’s responses were accurate) or Simultaneous Production (if the child is incorrect) and working on specific target utterances until the child is able to produce the target utterances correctly spontaneously at a normal rate and with varied prosody. The efficacy of DTTC for children with severe CAS has been demonstrated in three singlecase experimental design studies: Strand and Debertine (2000), Strand et al. (2006), and Bass et al. (2008). Other research by Edeal and Gildersleeve-Neumann (2011), Maas et al. (2012), and Maas and Farinella (2012) examined various principles of motor learning using a DTTC framework in children with CAS. Maas et al. (2019) used a modified DTTC approach to examine practice amount and distribution. These studies are described in greater detail in Chapter 3. A more recent study by Lim et al. (2019) found training school teaching assistants in using DTTC with children with CAS was an effective means of providing treatment at school. The following script in Box 4–1 encompasses approximately 5 minutes of a speech therapy session using DTTC. The script illustrates how cues can be delivered and faded in a dynamic manner following each of the child’s responses.

Figure 4–14.  DTTC flowchart. (“Dynamic Temporal and Tactile Cueing: A Treatment Strategy for Childhood Apraxia of Speech,” by E. A. Strand, 2020, American Journal of Speech-Language Pathology, 29, pp. 35, Figure 3. Reproduced with permission from ASHA.)

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   187

188   Here’s How to Treat Childhood Apraxia of Speech

Box 4–1.  Script Illustrating the Use of DTTC in Treatment [The child is placing small cars at the top of a slide behind a gate. The child’s job is to release the cars, and the clinician’s job is to open the gate.] Clinician:  “Let me know when you’re ready for the gate to open.” [Open is the target utterance. The clinician secures the child’s visual attention prior to modeling the target word (Cueing technique: Direct imitation)] Child: [oʊ ə] Clinician: “Open.” That’s a tricky word. Let’s say it together.” [The clinician secures the child’s visual attention and produces the word at a reduced rate using prolonged vowels simultaneously with the child. (Cueing techniques: Rate reduction and simultaneous production)] Clinician: “Open.” Child: [oʊ.pə] Clinician:  “Let’s try again. Be sure to finish the word. It has the ‘nnn’ noisy nose sound at the end. Opennn.” (Cueing techniques: Metaphor and model) Clinician:  “Let’s say it together. Open.”  Child: [oʊ.pə] [The clinician produces the word along with the child. (Cueing techniques: Rate reduction and simultaneous production.)] Clinician:  “I didn’t hear the ‘nnn’ noisy nose sound at the end.” (Feedback: Knowledge of production. Cueing technique: Metaphor). “Opennn. Lift your tongue at the end.” (Cueing techniques: Delayed imitation and phonetic placement cue) “Let me help you with this one.” [The clinician produces the word along with the child but adds a tactile prompt to cue the child for the final /n/. (Cueing techniques: Simultaneous production, rate variation, and tactile cue.)] Clinician: “Open.” Child: [oʊ.pən] Clinician:  “Great! You used your noisy nose sound!” (Feedback: Knowledge of production) [The clinician opens the gate, and the car is released.] “Let’s say it together again.” Clinician: “Open, open open.” Child: [oʊ.pən, oʊ.pən, oʊ.pən] [The clinician opens the gate.] Clinician:  “Great! You remembered your noisy nose sound every time.” (Feedback: Knowledge of production; Cueing technique: Metaphor) [After the child has produced the target utterance open correctly three to five times with the combined simultaneous production and tactile cueing (which was the required level of cueing to achieve a correct response), the clinician will begin to fade the cues systematically. On the next attempt, the clinician will omit the tactile cue but use simultaneous production.] Clinician:  “Here’s another car. We need to . . . open, open, open.” Child: [oʊ.pən, oʊ.pən, oʊ.pən] (Cueing technique: Simultaneous production with increased rate of production). [The clinician opens the gate, releasing another car.] Clinician:  “That’s perfect!” (Feedback: Knowledge of results).

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   189

Box 4–1.  continued [Because the child was able to produce the utterance with simultaneous production at a normal rate, the clinician will model the target word open just prior to the child producing the word.] Clinician:  “Let me know when you want the gate to open.” (Cueing technique: Direct imitation) Child: [oʊ.pən] [The child produces the word correctly but uses a slow rate of production.] Clinician:  “You did it!” (Feedback: Knowledge of results). [To facilitate a normal rate of production, the clinician will mime the target word open as the child produces it to establish an increased rate. The clinician holds up three fingers to indicate the word should be produced three times and mimes “open” while the child produces it. (Cueing technique: Miming) Child: [oʊ.pən, oʊ.pən, oʊ.pən] Clinician:  [The clinician opens the gate.] “Very nice!” (Feedback: Knowledge of results.) “We’ve got three more cars. Which one goes down the ramp next?” Child:  [The child points to the preferred car.] Clinician:  “Let me know when we should open the gate, okay?” (Cueing technique: Delayed imitation) [The clinician holds up three fingers to indicate three trials.] Child: [oʊ.pən, oʊ.pə, oʊ.pə] Clinician:  “Try again. Be sure to put your ‘nnn’ noisy nose sound at the end of each word like this, opennn.” (Feedback: Knowledge of results. Cueing techniques: Metaphor and direct imitation.) Child: [oʊ.pən, oʊ.pən, oʊ.pən] Clinician:  [The clinician opens the gate.] “Correct! You remembered to lift your tongue at the end!” (Feedback: Knowledge of performance).

The preceding script illustrates several important concepts related to the DTTC model, including the following: • The level of cueing, frequency of feedback, and type of feedback were varied after each of the child’s responses. • Initially the feedback was delivered after each response and later after a set of responses (intermittent feedback). • Initially the feedback was delivered in the form of specific feedback (KP ) and later as nonspecific feedback (KR). • The child’s rate of production was reduced to achieve initial success and then was increased as the child became more successful to facilitate generalization. • A variety of cues were added as needed (simultaneous production, miming, direct imitation, phonetic placement, metaphors, and tactile cues; see Chapter 3 for descriptions of these cues) to establish initial success.

190   Here’s How to Treat Childhood Apraxia of Speech

• Cues were faded as the child became more successful (simultaneous production to direct imitation to delayed imitation); see Chapter 3 and then added back again (delayed imitation to direct imitation) when the child’s productions were inaccurate to support errorless learning. The URLs to the Strand (2020) tutorial for DTTC as well as an in-depth, online course regarding Assessment and Treatment of CAS using DTTC from Child Apraxia Treatment (Once Upon a Time Foundation) are listed in Table 4–4.

Motor Speech Treatment Protocol The Motor Speech Treatment Protocol (MSTP; Namasivayam et al., 2015) incorporates principles of motor learning (e.g., mass and distributed practice opportunities, feedback provided related to both KP and KR) in combination with multisensory cueing strategies (visual, auditory, tactile) and gradual manipulation of a delay between the clinician’s model and the child’s performance. The target utterances progress from simple to more complex and are “practiced in structured play activities using functional words and phrases that are meaningful to the child and family” (p. 533). During MSTP sessions, the child’s caregiver is present and is an active participant in the treatment process. After homework is reviewed, the targets are introduced to the child, followed by practice of the treatment targets in three or four more naturalistic activities (e.g., shared book reading, game, or craft). Throughout the sessions, the caregiver is provided with opportunities to practice treatment strategies that will support the child’s speech practice at home. Research by Namasivayam et al. (2015) investigated the effects of treatment dose frequency on 37 children with CAS undergoing MSTP intervention during a 10-week treatment block. The results of the study indicated that children receiving higher treatment dose frequency (2 times/week) had significantly better outcomes than children receiving lower treatment dose frequency (1 time/week) in articulation and functional communication. Although articulation and functional communication improved in the higher dose frequency group, neither group showed significant improvement in overall speech intelligibility at the single-word or sentence level after 10 weeks of treatment. It may be that children with CAS need more than a 10-week block of time to demonstrate improved overall intelligibility. In the Namasivayam et al. article, a fidelity checklist is included that provides supervising clinicians a structured way to determine if the treating clinician is adhering to the MSTP protocol. This fidelity checklist could be beneficial for use with other motor speech treatment programs.

Integrated Phonological Awareness Intervention The Integrated Phonological Awareness (IPA) intervention was designed to facilitate improved speech and phonological awareness development in preschool and early elementary-age children with speech disorders who have accompanying phonological awareness challenges. According to McNeill and Gillon (2021), “words containing target speech sounds or patterns are used as stimuli during phonological awareness activities to strengthen phonological representations that drive speech production” (p. 111).

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   191

McNeill et al. (2009) and Hume et al. (2018) examined the effects of an IPA program to simultaneously address speech production, phonemic awareness, and letter-sound knowledge. An underlying assumption of the treatment was that strengthening phonological representations in children with CAS could facilitate improvements in speech production, phoneme awareness, and sound-letter association. Phonological awareness tasks included activities to strengthen sound-letter associations, blending, segmenting, and phoneme manipulation. The clinicians chose words for the phonological awareness activities that shared characteristics of the speech targets. For example, if the child was working on suppression of cluster reduction of /s/ initial clusters (e.g., stop, spot, stick), the child would practice production of /s/ clusters (to strengthen speech) and also work on blending and segmenting the individual sounds in these /s/ cluster targets (to strengthen phoneme awareness). The findings of these studies suggest that IPA facilitates improved phonological awareness and speech development in some children with CAS. Gillon and McNeill (2007) have provided a thorough online resource manual describing IPA and providing suggestions of activities for treatment, as well as a website to locate picture resources for IPA. The URLs for these information sources can be found in Table 4–4.

Rapid Syllable Transition (ReST) Treatment ReST was designed to facilitate improvement in the following core features of CAS described by the American Speech-Language-Hearing Association (ASHA, 2007): • phoneme accuracy and consistency • appropriate lexical stress • speed and fluidity of transitions from one syllable to the next In the ReST model, these three features are referred to as “sounds,” “beats,” and “smoothness” (McCabe et al., 2020). To achieve these goals, ReST incorporates intensive practice (≥100 trials per session) in production of two- to three-syllable phonotactically permissible pseudo-words (e.g., CVCV /ˈbɑ.də/; CVCVCV /bə.ˈdɑ.fi/) in single words and in carrier phrases (e.g., “I want a [ˈbɑ.də].” “Go to the [bə.ˈdɑ.fi]”). By using pseudo-words, the learner is able “to practice motor planning and programming on word-like forms without interference from previously incorrectly learned plans” (Thomas et al., 2014, p. 2). Because of the nature of the program, ReST is recommended for children ages 4–13 years with mild-to-severe CAS who are able to sustain attention to structured tabletop work (McCabe et al., 2013). To determine if ReST is a good fit for a child, the authors have created a ReST Readiness Checklist with questions to help identify which children may benefit from this treatment. The URL for the Readiness Checklist can be found in Table 4–4. The online therapy manual provides a flowchart (as shown in Figure 4–15) to guide decisions about where to begin in treatment. The online therapy manual and other materials and resources are available on the ReST website, and the URLs for those resources are listed in Table 4–4. Some of these resources include a list of polysyllabic words and sentences to use for assessments and/or follow-up probes, sample ReST cards and wordlists, and sample data sheets to transcribe the child’s responses and identify if the sounds, beats, and smoothness were correct. When using the word lists from the website, keep in mind that the program is from Australia and, hence, when the

192   Here’s How to Treat Childhood Apraxia of Speech

Figure 4–15.  ReST goal setting flowchart. (“Clinical Manual for Rapid Syllable Transition Treatment [ReST],” by P. McCabe, E. Murray, D. Thomas, and P. Evans, 2017, p. 9. Reproduced with permission from Patricia McCabe.)

stimuli include vocalic /r/, it is not actually pronounced. For example, the word “farbakee” is actually pronounced as /ˈfɑ.bə.ki/. Instructions are provided on how to make your own stimuli for two- and three-syllable nonsense words. When creating your own nonsense word lists, you are choosing four consonants and three vowels plus a shwa. For two-syllable words, strong-weak and weak-strong (WS) stress patterns are used. For three-syllable words, strongweak-weak (SWW) and weak-strong-weak (WSW) stress patterns are used. To keep track of the syllable you need to stress, it helps to write your stimuli in International Phonetic Alphabet with the stress marks. It is also helpful to remember that the unstressed syllable in the first or second syllable position will always be a schwa. In Table 4–2, examples of target words are

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   193

listed for two-syllable nonsense words containing the consonant phonemes /f, d, b, k/ and the vowels /i, ɑ, oʊ, ə/; in Table 4–3, the same consonant and vowel phonemes are used in three-syllable nonsense words. Various principles of motor learning (described in Chapter 3) guide the design of the ReST treatment protocol (Murray et al., 2012, 2015). • pre-practice to ensure task understanding and allow the learner to experience accurate production of targets • practice variability incorporating phonemes with varied place, manner, and voicing characteristics, as well as varied syllable stress patterns • a high number of production trials completed each session, with the targets practiced in random order • feedback provided as KP in the Pre-practice portion, and KR in the Practice portion of the session This treatment protocol has shown positive results for supporting improvement in each of ASHA’s specified core challenge areas for children with CAS (segmental accuracy/consistency, coarticulation, and prosody). An RCT was conducted comparing ReST and Nuffield Dyspraxia Programme 3rd Edition (NDP3; NDP3 was described earlier). The study found positive efficacy results for both programs (Murray et al., 2015). The developers of the ReST program have created a clinical manual that can be accessed online (McCabe et al., 2017), as well as a tutorial describing the ReST program (McCabe et al., 2020). These materials provide detailed information about the ReST program, including how to determine if an individual is a good candidate for the program, how to develop treatment materials and target word lists for treatment, and how to track progress. Table 4–2.  Sample ReST Two-Syllable Stimuli Strong-Weak

Weak-Strong

ˈki.də

kə.ˈdi

ˈboʊ.də

bə.ˈdoʊ

ˈfɑ.bə

fə.ˈbɑ

ˈdoʊ.fə

də.ˈfoʊ

ˈdi.kə

də.ˈki

Table 4–3.  Sample ReST Three-Syllable Stimuli Strong-Weak-Weak

Weak-Strong-Weak

ˈfɑ.bə.kə

fə.ˈbɑ.kə

ˈkɑ.bə.fi

kə.ˈbɑ.fi

ˈdi.fə.bə

də.ˈfi.bə

ˈboʊ.də.fə

bə.ˈdoʊ.fə

ˈkoʊ.fə.bi

kə.ˈfoʊ.bi

194   Here’s How to Treat Childhood Apraxia of Speech

Visual Biofeedback Children with CAS are believed to rely more than children with typical speech development on sensory feedback (the auditory signal following the child’s speech production) as a result of poor feedforward control. Terband et al. (2009) suggest two possible causes of poor feedforward control: (a) reduced somatosensory awareness and (b) “an increased level of neural noise” (p. 1606). Because children with CAS often have compromised sensory feedback of their speech production, which can impact knowing where their articulators are in space, it is helpful to augment therapy with visual feedback. Visual biofeedback techniques often utilize technology to provide feedback about accuracy of production of target utterances. A most basic form of visual biofeedback would be the use of a mirror so the child can see if the production is correct (e.g., reducing tongue protruding during production of /l/, facilitating upper teeth contact with the lower lip for /f/). Two types of technology, ultrasound biofeedback and electropalatography, are discussed here.

Ultrasound Biofeedback Ultrasound biofeedback utilizes ultrasound technology to provide real-time visual feedback of the tongue to facilitate correct production of lingual sounds such as /r, s, l, k, tʃ/. During treatment, an ultrasound probe is placed beneath the chin in one of two directions depending on the view you want to achieve (sagittal or dorsal). The child can view tongue movement on a computer screen in real time during treatment. Descriptions and drawings of the tongue shape and position are provided for comparison of the child’s production and the targeted production. For some older children with CAS who have persistent articulation errors, ultrasound biofeedback has been found to be effective in developing increased phoneme accuracy and improved overall speech intelligibility (Preston et al., 2013, 2017). Refer to Figure 4–16A and Figure 4–16B to see sagittal views of correct and incorrect productions of /r/. Figure 4–16C and Figure 4–16D illustrate coronal views of correct and incorrect /s/ production. It should be noted that the use of visual biofeedback techniques, such as ultrasound biofeedback, should be implemented as part of a motor-based treatment approach when working with children with CAS. Thus, other principles of motor learning would be adhered to during treatment, such as a high number of production trials, careful selection of target utterances to challenge, without overtaxing the motor speech system, and incorporation of pre-practice to shape some accurate productions of the targeted phonemes prior to the practice phase of treatment.

Electropalatography Electropalatography (EPG) is instrumentation that provides real-time visual feedback of tongueto-palate contacts and lip closure contacts. An acrylic palate is created from a dental mold of the child’s palate. The acrylic palate is covered with over 100 electrodes and is connected to a computer via a USB cable. Both the client and the clinician wear an acrylic palate, and each person’s palatal contacts are represented on a split screen on a computer. The client attempts to achieve predetermined placement of the tongue for a specified phoneme by matching the visual display during production of the phoneme in isolation, words, phrases, and sentences. This technology is typically used for children from elementary school through adulthood who

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   195

A

B

C

D

Figure 4–16.  A. Ultrasound image sagittal view correct production of /ɚ/. B. Ultrasound image sagittal view incorrect production of /ɚ/. C. Ultrasound image coronal view correct production of /s/. D. Ultrasound image coronal view incorrect production of /s/.

have struggled to achieve certain lingual consonant phonemes or lip-to-lip contact phonemes with the ultimate goal being improvement of speech intelligibility. Lundeborg and McAllister (2007) provided evidence of improvement of articulation of persistent speech sound errors in children with CAS. The most frequently used EPG system on the market currently is the SmartPalate system by CompleteSpeech (more information about the SmartPalate can be found at https://completespeech.com/smartpalate/). Figure 4–17A shows a display of the tongue-to-palate contact for correct production of /ɚ/, whereas Figure 4–17B shows an incorrect production of /ɚ/. Figure 4–18A and 4–18B show displays of tongue-to-palate contact for correct and incorrect production of /k/, respectively. In Figure 4–18C, the child substitutes /t/ for /k/.

Treatments With Preliminary Evidence Some treatments for CAS have some preliminary evidence of their effectiveness with children with CAS. Two of these programs are discussed next.

Babble Boot Camp Typically, speech and language therapy is initiated after a child shows signs of a speech and/ or language delay. Children with classic galactosemia (CG) are known to be at high risk of

196   Here’s How to Treat Childhood Apraxia of Speech

A

B

Figure 4–17.  A. EPG display of tongue-to-palate contact for correct /ɑr/ using SmartPalate. B. EPG display of tongue-to-palate contact for incorrect /ɑr/ using SmartPalate.

A

B

Figure 4–18.  A. EPG display of tongue-to-palate contact for correct /k/ using SmartPalate. B. EPG display of tongue-to-palate contact illustrating distorted /k/ production using SmartPalate. C. EPG display of tongue-to-palate contact illustrating /t/ for /k/ substitution using SmartPalate.

C

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   197

speech and language disorders (Peter et al., 2021). Babble Boot Camp (BBC) was first developed for infants with CG because of their known risk for developing motor speech disorders. Rather than being a reactive treatment, BBC is a proactive intervention model, in which parents are coached via telepractice to implement prespeech, early speech, language stimulation, and language expansion activities in the home (Peter et al., 2021). During the program, parents are trained by an SLP to engage in 17 age-appropriate activities and routines throughout the day that foster communication skills (dyadic interactions, cooing and babbling, use of first words and sentences, vocabulary, and syntax development). These 17 activities and routines are described at the Open Science Framework entry for the BBC (https://osf.io/yzht4/). Examples of activities and routines include responding to baby’s coos by imitating what the baby said or saying something back to the baby; showing the baby videos of other babies babbling; stimulating babble by modeling babbling and by gently moving the baby’s lips while the baby is vocalizing; pairing gestures and words (e.g., raising arms up for “up” or motioning to “come here”); creating a photo communication book with pictures of important family and friends, favorite foods, and toys, and labeling the pictures in the book as the child looks at the book; and expanding the child’s single words with two-word phrases (e.g., baby says, “ball,” and parent says, “big ball”). A more detailed description of BBC can be found in Chapter 6.

Kaufman Speech to Language Protocol The Kaufman Speech to Language Protocol (K-SLP) is a full treatment approach that addresses challenges of children with CAS in the areas of speech, language, and functional communication. K-SLP promotes shaping target words by simplifying motor plans of words/phrases while gradually shaping the child’s speech toward accurate productions. The clinician examines the child’s production of each target utterance and determines the best approximations to teach to give the child a way to produce the target words in a consistent way as intelligibly as possible. Simplifications of words are chosen based on normal phonological patterns younger children often use when learning speech and are gradually shaped into accurate productions of the target utterances. For example, when teaching the child to say, “bottle,” the clinician may initially model “ba” (syllable deletion), then “baba” (reduplication), then “bah doe” (prevocalic voicing and liquid gliding), and eventually, “bottle.” Target utterances selection is based on the phonemes and syllable shapes within the child’s repertoire, as well as common nouns and functional vocabulary that are meaningful for the child (e.g., favorite foods and toys, names of family members and friends). While working on speech, language is simultaneously being addressed using functional phrases and carrier phrases/pivot phrases to support the child’s expressive language development. When implementing the K-SLP approach, the SLP evaluates where the child is in their motor speech development and figures out the best approximations to teach the child to give them a way to use language and understand the power of language while gradually working toward accurate production of target utterances. The approximations chosen should be the closest approximations of the target utterance the child is able to produce with a high level of accuracy when provided with cueing. Parents and caregivers are provided with coaching to help the child retain their skills in the natural environment and through play. Parents are encouraged to replace the child’s typical patterns of communication (e.g., grunts, fussing) with the best possible productions of functional utterances based on common nouns and favorite things and to work on these to perfection. The theoretical underpinnings of K-SLP

198   Here’s How to Treat Childhood Apraxia of Speech

are based on the principles of applied behavior analysis. The program features the following teaching strategies: • Define the target speech and language behaviors to be addressed through the process of evaluation. • Determine target utterances based on assessment and parent/child input. • Simplify the target utterances based on phonological patterns that would be typical of early speech development and are within the sensorimotor speech capacities of the child. • Use multisensory cues to establish a high level of accuracy. • Fade cues gradually to facilitate maintenance and generalization of the targets. • Use highly preferred items to reinforce and motivate the child. • Mix and vary the tasks to support generalization. • Facilitate early language development by incorporating target utterances into functional phrases (I do, me too) and pivot phrases (e.g., put in ____, open ____, I got ___). Several picture resources are available to support the SLP in the implementation of K-SLP. The K-SLP Treatment Kits include picture cards that are sorted by syllable shape complexity and phonetic features and can be used to provide a visual referent for children to move from imitation to labeling, and ultimately to requesting and commenting in the natural environment. Each picture in the kits has a picture on the front and suggested approximations on the back. The SLP is encouraged to try to facilitate the best production beginning with the correct production and simplifying as needed to reach the closest approximation possible for the child at the point in time. Other books and materials are available to practice functional phrases of increased length and complexity. The Sign to Talk Kits, created by Kasper and Kaufman, are used as resources to implement sign language as a bridge to vocal communication especially for those with autism spectrum disorder (ASD). Figure 4–19 shows examples of K-SLP Treatment Kit materials showing the front and backs of picture cards with the pictures on the front and the target utterances and suggested approximations on the back. The URL for videos and available materials for the K-SLP is found in Table 4–4. Gomez et al. (2018) collected preliminary evidence on the use of K-SLP with two children and found some evidence for the effectiveness of this approach in children with CAS. Both children in the study improved their percentage phonemes correct on treated words, and the accuracy of these treated words was maintained during the maintenance phase of the study. One of the children in the study showed some generalization of gains to untrained words following the 3 weeks of intensive treatment (four sessions per week). Additional studies of K-SLP are forthcoming.

Online Resources for EBP Programs A variety of resources can be found online to learn more about the EBP programs described in this chapter or to view the online materials. The URL for each resource is provided in Table 4–4.

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   199

Figure 4–19.  Sample K-SLP Treatment Kit 1 pictures. (N. Kaufman, 2013 Used with permission from Nancy Kaufman.)

Table 4–4.  Online Resources to Learn More About Evidence-Based Programs for CAS

Program

Type of Resource

Website

Babble Boot Camp (BBC)

Open-source activities and routines of BBC

https://osf.io/sy3en/

BBC

Open-source article

https://pubs.asha.org/doi/full/10.1044/2021_AJSLP-2100098?af=R

Dynamic Temporal and Tactile Cueing (DTTC)

Online course

https://www.childapraxiatreatment.org/diagnosis-andtreatment-of-cas-online-course/

DTTC

Tutorial article

https://pubs.asha.org/doi/pdf/10.1044/2019_AJSLP-190005

Integrated Phonological Awareness (IPA) Program

Manual

https://www.canterbury.ac.nz/media/documents/ education-and-health/gail-gillon---phonologicalawareness-resources/programmes/preschool/01Integrated-Phonological-Awareness-Manual-Sept-07.pdf

IPA Program

Additional treatment resources/pictures

https://www.canterbury.ac.nz/education-and-health/ research/phonological-awareness-resources/

Nuffield Dyspraxia Programme Third Edition (NDP3)

Website 

http://www.ndp3.org

continues

200   Here’s How to Treat Childhood Apraxia of Speech

Table 4–4.  continued Kaufman Speech to Language Protocol (K-SLP)

Website to locate online materials and webinars

https://www.northernspeech.com/search/author/Nancy_ Kaufman/

Rapid Syllable Transition Treatment (ReST)

Program manual

https://rest.sydney.edu.au/wp-content/uploads/2019/07/ rest-clinician-manual.pdf

ReST

Additional resources

https://rest.sydney.edu.au/resources/

ReST

Tutorial article

https://pubs.asha.org/doi/full/10.1044/2020_PERSP-1900165

References American Speech-Language-Hearing Association. (n.d.). Key steps in infusing evidence into CE course content: Step 2. https://www.asha.org/ce/for-providers/ebce​ step2/ American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical report]. https:// www.asha.org/policy/ Baas, B., Strand, E. A., Elmer, L., & Barbaresi, W. (2008). Treatment of severe childhood apraxia of speech in a 12-year-old male with CHARGE association. Journal of Medical Speech-Language Pathology, 16, 180–190. https://dx.doi.org/10.1002/14651858.CD006278. pub3 Baker, E., & McLeod, S. (2008, November). EBP and speech sound disorders: An anthology of 120 peer reviewed studies of phonological intervention 1978–2008 [Paper presentation]. American Speech-Language-Hearing Association Convention, Chicago, IL, United States. Caruso, A. J., & Strand, E. A. (1999). Motor speech disorders in children: Definitions, background, and a theoretical framework. In A. J. Caruso & E. A. Strand (Eds.), Clinical management of motor speech disorders in children (pp. 1–27). Thieme. Chumpelik, D. A. (1984). The PROMPT system of therapy: Theoretical framework and applications for developmental apraxia of speech. Seminars in Speech and Language, 5, 139–155. https://doi.org/10.1055/s-​ 0028-1085172 Dale, P. S., & Hayden, D. A. (2013). Treating speech subsystems in childhood apraxia of speech with tactual input: The PROMPT approach. American Journal of Speech-Language Pathology, 22, 644–661. https:// doi.org/10.1044/1058-0360(2013/12-0055)

Davis, B. L., Jakielski, K. J., & Marquardt, T. P. (1998). Developmental apraxia of speech: Determiners of differential diagnosis. Clinical Linguistics & Phonetics, 12, 25–45. https://doi.org/10.3109/02699209808985211 Edeal, D. M., & Gildersleeve-Neumann, C. E. (2011). The importance of production frequency in therapy for childhood apraxia of speech. American Journal of Speech-Language Pathology, 20, 95–110. https://doi​ .org/10.1044/1058-0360(2011/09-0005) Gillon, G. T., & McNeill, B. C. (2007). Integrated phonological awareness: An intervention program for preschool children with speech-language impairment. College of Education, University of Canterbury, New Zealand. https://www.canterbury.ac.nz/media/documents/ education-and-health/gail-gillon---phonologicalawareness-resources/programmes/preschool/01Integrated-Phonological-Awareness-Manual-Sept07.pdf Gomez, M., McCabe, P., Jakielski, K., & Purcell, A. (2018). Treating childhood apraxia of speech with the Kaufman Speech to Language Protocol: A phase 1 pilot study. Language, Speech, and Hearing Services in Schools, 49, 524–536. https://doi.org/10.1044/2018_ LSHSS-17-0100 Hayden, D. A. (2004a). P.R.O.M.P.T.: A tactually grounded treatment approach to speech production disorders. In I. Stockman (Ed.), Movement and action in learning and development: Clinical implications for pervasive developmental disorders (pp. 255–297). Elsevier-Academic Press. Hayden, D. A. (2004b). P.R.O.M.P.T. Prompts for restructuring oral muscular phonetic targets, introduction to technique: A manual. PROMPT Institute.

4.  Evidence-Informed Decision-Making in Treatment of Childhood Apraxia of Speech   201 Hayden, D. A. (2006). The PROMPT model: Use and application for children with mixed phonological-motor impairment. Advances in Speech Pathology, 8, 265– 281. https://doi.org/10.1080/14417040600861094 Hayden, D. A. (2008). P.R.O.M.P.T. Prompt for restructuring oral muscular phonetic targets, introduction to technique: A manual (2nd ed.). PROMPT Institute. Higginbotham, J., & Satchidanand, A. (2019). From triangle to diamond: Recognizing and using data to inform our evidence-based practice. ASHA Journals Academy. https://academy.pubs.asha.org/2019/04/ from-triangle-to-diamond-recognizing-and-usingdata-to-inform-our-evidence-based-practice/ Hume, S. B., Schwarz, I., & Hedrick, M. (2018). Preliminary investigation of the use of phonological awareness paired with production training in children with apraxia of speech. Perspectives of the ASHA Special Interest Groups SIG 16, 3, 38–52. https://doi​ .org/10.1044/persp3.SIG16.38 Kadis, D. S., Goshulak, D., Namasivayam, A., Pukonen, M., Kroll, R., De Nil, L. F., . . . Lerch, J. P. (2014). Cortical thickness in children receiving intensive therapy for idiopathic apraxia of speech. Brain Topography, 27, 240–247. https://doi.org/10.1007/s10548-013-0​ 308-8 Kaufman, N. (2013). Kaufman Speech to Language Protocol Treatment Kits 1 & 2 (Manual). Nothern Speech Services. Lim, J., McCabe, P., & Purcell, A. (2019). “Another tool in my toolbox”: Training school teaching assistants to use dynamic temporal and tactile cueing with children with childhood apraxia of speech. Child Language Teaching and Therapy, 3, 241–256. https:// doi.org/10.1177/0265659019874858 Lundeborg, I., & McAllister, A. (2007). Treatment with a combination of intra-oral sensory stimulation and electropalatography in a child with severe developmental dyspraxia. Logopedics Phoniatrics Vocology, 32, 71–79. https://doi.org/10.1080/14015430600852035 Maas, E., Butalla, C. E., & Farinella, K. A. (2012). Feedback frequency in treatment for childhood apraxia of speech. American Journal of Speech-Language Pathology, 21, 239–257. https://doi.org/10.1044/10580360(2012/11-0119) Maas, E., & Farinella, K. A. (2012). Random versus blocked practice in treatment of childhood apraxia of speech. Journal of Speech, Language, and Hearing Research, 55, 561–578. https://doi.org/10.1044/10924388(2011/11-0120) Maas, E., Gildersleeve-Neumann, C., Jakielski, K., Kovacs, N., Stoeckel, R., Vradelis, H., & Welsh, M. (2019). Bang for your buck: A single-case experimental design study of practice amount and distribution in treatment for childhood apraxia of speech.

Journal of Speech, Language, and Hearing Research, 62, 3160–3182. https://doi.org/10.1044/2019_JSLHR-​S-​ 18-0212 McCabe, P., Murray, E., Thomas, D. C., Bejjani, L., & Ballard, K. J. (2013, November). A new evidence-based treatment for childhood apraxia of speech: ReST [Paper presentation]. American Speech-Language-Hearing Association Annual Convention, Chicago, IL, United States. McCabe, P., Murray, E., Thomas, D., & Evans, P. (2017). Clinician manual for rapid syllable transition treatment. The University of Sydney, Camperdown, Australia. McCabe, P., Thomas, D. C., & Murray, E. (2020). Rapid syllable transition treatment — A treatment for childhood apraxia of speech and other pediatric motor speech disorders. Perspectives of the ASHA Special Interest Groups, 5, 821–830. https://doi.org/10.10​44/​ 2020_PERSP-19-00165 McKechnie, J., Ahmed, B., Gutierrez-Osuna, R., Murray, E., McCabe, P., & Ballard, K. J. (2020). The influence of type of feedback during tablet-based delivery of intensive treatment for childhood apraxia of speech. Journal of Communication Disorders, 87, 106026. https://doi.org/10.1016/j.jcomdis.2020.106026 McNeill, B. C., & Gillon, G. T. (2021). Integrated phonological awareness intervention. In A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), Interventions for speech sound disorders in children (2nd ed.). Paul H. Brookes. McNeill, B. C., Gillon, G. T., & Dodd. B. (2009). Effectiveness of an integrated phonological awareness approach for children with childhood apraxia of speech (CAS). Child Language Teaching and Therapy, 25, 341–366. https://doi.org/10.1177/026565900933​9823 Murray, E., McCabe, P., & Ballard, K. J. (2012). A comparison of two treatments for childhood apraxia of speech: Methods and treatment protocol for a parallel group randomised control trial. BMC Pediatrics, 12. https://doi.org/10.1186/1471-2431-12-112 Murray, E., McCabe, P., & Ballard, K. J. (2015). A randomized controlled trial for children with childhood apraxia of speech comparing Rapid Syllable Transition Treatment and the Nuffield Dyspraxia Programme (3rd ed.). Journal of Speech, Language, and Hearing Research. https://doi.org/10.1044/2015_ JSLHR-​S-13-0179 Namasivayam, A. K., Huynh, A., Granata, F., Law, V., & van Lieshout, P. (2021). PROMPT intervention for children with severe speech motor delay: A randomized control trial. Pediatric Research, 89, 613–621. https://doi.org/10.1038/s41390-020-0924-4 Namasivayam, A. K., Pukonen, M., Goshulak, D., Hard, J., Rudzicz, F., Rietveld, T., . . . van Lieshout, P.

202   Here’s How to Treat Childhood Apraxia of Speech (2015). Treatment intensity and childhood apraxia of speech. International Journal of Language and Communication Disorders, 50, 1–18. https://doi.org/10.11​ 11/1460-6984.12154 Olswang, L. B., & Bain, B. (1994). Data collection: Monitoring children’s treatment progress. American Journal of Speech-Language Pathology, 3, 55–66. https:// doi​.org/10.1044/1058-0360.0303.55 Peter, B., Davis, J., Cotter, S., Belter, A., Williams, E., Stumpf, M., . . . Potter, N. (2021). Toward preventing speech and language disorders of known genetic origin: First post-intervention results of Babble Boot Camp in children with classic galactosemia. American Journal of Speech-Language Pathology, 30, 2616– 2634. https://doi.org/10.1044/2021_AJSLP-21-00098 Preston, J. L., Brick, N., & Landi, N. (2013). Ultrasound biofeedback treatment for persisting childhood apraxia of speech. American Journal of Speech-Language Pathology, 22, 627–643. https://doi.org/10.1044/10580360(2013/12-0139) Preston, J. L., Leece, M. C., McNamara, K., & Maas, E. (2017). Variable practice to enhance speech learning in ultrasound biofeedback treatment for childhood apraxia of speech: A single case experimental study. American Journal of Speech-Language Pathology, 26, 840–852. https://doi.org/10.1044/2017_AJSLP-160155 Randazzo, M. (2019). A survey of clinicians with specialization in childhood apraxia of speech. American Journal of Speech-Language Pathology, 28, 1659–1672. https://doi.org/10.1044/2019_AJSLP-19-0034 Rosenbek, J. (1985). Treating apraxia of speech. In D. Johns (Ed.), Clinical management of neurogenic communicative disorders (pp. 267–312). Little, Brown & Co. Rosenbek, J., Lemme, M., Ahern, M., Harris, E., & Wertz, T. (1973). A treatment for apraxia of speech in adults. Journal of Speech and Hearing Research, 26, 231–249. https://doi.org/10.1044/jshd.3804.462

Strand, E. A. (2020). Dynamic temporal and tactile cueing: A treatment strategy for childhood apraxia of speech. American Journal of Speech-Language Pathology, 29, 30–48. https://doi.org/10.1044/2019_AJSLP19-0005 Strand, E. A., & Debertine, P. (2000). The efficacy of integral stimulation intervention with developmental apraxia of speech. Journal of Medical SpeechLanguage Pathology, 8, 295–300. Strand, E. A., & Skinder, A. (1999). Treatment of developmental apraxia of speech: Integral stimulation methods. In A. J. Caruso & E. A. Strand (Eds.), Clinical management of motor speech disorders in children (pp. 109–148). Thieme. Strand, E. A., Stoeckel, R., & Baas, B. (2006). Treatment of severe childhood apraxia of speech: A treatment efficacy study. Journal of Medical Speech-Language Pathology, 14, 297–307. Terband, H., Maassen, B., Guenther, F. H., & Brumberg, J. (2009). Computational neural modeling of speech motor control in childhood apraxia of speech (CAS). Journal of Speech, Language, and Hearing Research, 52, 1595–1609. https://doi.org/10.1044/1092-4388​(2009/​ 07-0283) Thomas, D. C., McCabe, P., & Ballard, K. J. (2014). Rapid syllable transitions (ReST) treatment for childhood apraxia of speech: The effect of lower-dose frequency. Journal of Communication Disorders, 51, 29–42. https://doi.org/10.1016/j.jcomdis.2014.06.004 Williams, A. L., McLeod, S., & McCauley, R. J. (2021). Introduction. In A. L. Williams, S. McLeod, & R. J. McCauley (Eds.), Interventions for speech sound disorders in children (pp. 1–22). Paul H. Brookes. Williams, P., & Stephens, H. (2004). Nuffield Centre Dyspraxia Programme (3rd ed.). The Miracle Factory. World Health Organization. (2007). International classification of functioning, disability and health: Children and youth version: ICF-CY.

CHAPTER

5

Establishing Vowel Accuracy and Natural Prosody

A

lthough treatment programs for most children with speech sound disorders typically address improved production of consonant phonemes, most do not address the assessment and treatment of vowel production or prosody. Because challenges with vowels and prosody are features of the speech of children with childhood apraxia of speech (CAS), it is essential that treatment for children with CAS address vowels and prosody as well. These two topics are organized together in this chapter because of the strong interaction between vowels and prosody. Assessment and treatment of both vowels and prosody are discussed in this chapter.

Vowels Vowels are considered the nucleus of the syllable because, with few exceptions, each syllable contains a vowel. Vowels are different from consonants in their production, as consonants are produced by creating a vocal tract obstruction or constriction (e.g., lip closure for /b/, tongue contacts alveolar ridge for /t/), while vowels are produced with limited vocal tract constriction. They are made distinct from one another by altering the shape of the tongue, which alters the shape of the oral and pharyngeal cavities (Jakielski & Gildersleeve-Neumann, 2018).

Causes and Ramifications of Vowel Challenges in CAS Vowel errors, including vowel distortions and substitutions and limited vowel inventories are common in children with CAS (Davis et al., 1998; Rosenbek & Wertz, 1972). These errors can have a significant impact on overall speech intelligibility and prosody. Difficulty with diphthongs and rhotic vowels were consistent findings in children with CAS (Davis et al.,

203

204   Here’s How to Treat Childhood Apraxia of Speech

2005; Pollock & Hall, 1991; Shriberg et al., 1997). Pollock and Hall also noted difficulty with contrasting tense and lax vowels in neighboring vowel spaces (vowels that are close to one another on the vowel quadrilateral), such as /i/ and /ɪ/, as well as backing of vowels (e.g., substituting /ɑ/ for /æ/). What causes children with CAS to exhibit challenges with production of vowels? It is likely that limited vocal tract constriction during vowel production reduces the tactile/kinesthetic feedback the child receives, which contributes to the challenges of many children with CAS in accurate production of vowels. Vowel perception also may contribute to vowel production challenges. Maassen et al. (2003) reported that children with CAS performed more poorly than their same-age peers on tasks of vowel identification and discrimination. Difficulty with discrimination of the duration of vowels as well as the production of duration differences in children with CAS were observed by Ingram et al. (2019). The ramifications of poor vowel production are significant. Kent and Rountrey (2020) describe how vowels carry acoustical information that provides the listener with a great deal of information about the vowel being produced, the neighboring consonants, age and gender of the speaker, prosodic content of the utterance (e.g., stress, rhythm, intonation), and the mood or intention of the speaker. Vowels also give information about the degree of formality of the speaker, as vowels often are shortened or omitted in less formal connected speech. It is imperative for clinicians working with children with CAS to understand vowel production, develop strong skills in evaluating vowel accuracy, and learn methods to facilitate accurate production of vowels. This chapter provides an overview of vowel classification and production and addresses assessment and treatment of vowels.

Classification of Vowels We divide vowels into three basic categories: • monophthongs • diphthongs • rhotic diphthongs and triphthongs A brief discussion of the phonemes, /w/ and /j/, sometimes referred to as semivowels because of their vowel-like quality, also is included in this chapter.

Monophthongs Monophthongs, sometimes referred to as pure vowels, are vowels produced with a single articulatory movement. Figure 5–1 is a visual depiction of a vowel quadrilateral. This vowel quadrilateral illustrates both the vertical and horizontal movement of the tongue for production of each monophthong in the American English language. Tongue height refers to the vertical dimension or how close the tongue is from the roof of the mouth and is classified as high, mid, or low. Tongue advancement refers to the horizontal dimension or how far forward the tongue is positioned in the oral cavity and is classified as front, central, or back. The phonetic symbols for the vowels on the vowel quadrilateral illustrate the “approximate” location of the tongue during production of each vowel. The positions are considered

5.  Establishing Vowel Accuracy and Natural Prosody   205

Figure 5–1.  Vowel quadrilateral of monophthongs in American English.

approximate because vowel placement is influenced by neighboring consonants, such that a high front vowel is produced more anteriorly following an alveolar phoneme and slightly more posteriorly when it follows a velar phoneme. The highest and most anterior vowel /i/ as in me, beat, need is produced with the tongue close to the alveolar ridge. The lowest posterior vowel /ɑ/ as in hot, mom, stop is produced with the tongue low and back in the oral cavity. Try alternating between saying /i/ (long “e” sound) and /ɑ/ (short “o” sound) /i, ɑ, i, ɑ, i, ɑ/ several times and notice the movement of the tongue and jaw. Try again without moving the jaw and notice how the tongue retracts and lowers when shifting from /i/ to /ɑ/. These two phonemes are far from one another on the vowel quadrilateral, and the change in articulatory position is quite noticeable. Now try alternating between /i/ and /ɪ/ (short “i” sound as in hit, sit, sick) /i, ɪ, i, ɪ, i, ɪ/. Notice how the movement of the tongue is much more subtle, and imagine how making such subtle shifts would be challenging for a child with reduced somatosensory awareness. Keep this in mind later in the chapter when talking about evaluation and treatment of vowel productions.

Vowel Diphthongs Vowel diphthongs bring two vowels together dynamically by rapidly gliding the tongue and lips from one articulatory position to another. The combining of the two vowels requires the speaker to change the shape of the vocal tract by shifting the position and shape of the tongue and shape of the lips during production quickly and fluidly enough that the production is perceived as a single vowel. There are three vowel diphthongs in the English language including /aɪ/ (bye ye), /aʊ/ (now ow), and /ɔɪ/ (boy oy). There are also two monophthong vowels, /e/ (hay ay) and /o/ (no o), that sometimes, though not always, are produced as diphthongs /eɪ/ and /oʊ/. Because we recognize the vowels in /ne/ and /neɪ/ and those in /no/ and /noʊ/ as the same vowels, they are considered allophones (variations of the same phoneme). The vowel quadrilateral in Figure 5–2 illustrates the articulatory gliding for the diphthongs /aɪ/, /aʊ/, and /ɔɪ/, as well as the /eɪ/ and /oʊ/.

206   Here’s How to Treat Childhood Apraxia of Speech

Figure 5–2.  Quadrilateral of American English vowel diphthongs.

Rhotic Vowels Rhotic vowels are vowels in which a rhotic /r/ functions as a vowel. The underlined vowels in the words her er, stir ir, blur urt, butter erfly, father er, and per erfect are rhotic vowels. Rhotics occurring in a stressed syllable are transcribed as /ɝ/ and in an unstressed syllable as /ɚ/. Rhotic diphthongs result when a rhotic vowel follows a monophthong /ɪ, ɛ, ʊ, ɔ, ɑ/ to create the diphthongs /ɪɚ, ɛɚ, ʊɚ, ɔɚ, ɑɚ/. Rhotic triphthongs result when a rhotic vowel follows a diphthong /aɪ, aʊ, ɔɪ/ to create a triphthong /aɪɚ, aʊɚ, ɔɪɚ/. That is, the symbol /ɑ/, should be changed to /a/. Phonetic symbols representing each monophthong, diphthong, and rhotic diphthong/ triphthong are shown in Table 5–1 along with corresponding words containing each vowel.

Glides The glides /w/ and /j/ (“y”) sometimes are referred to as semivowels because they are “vowellike” and produced in a similar manner to diphthongs or triphthongs. During production of /w/, the lips are rounded, and the tongue is positioned high and back (as in the vowel /ʊ/), then the tongue is quickly glided toward the vowel that follows (e.g., /ʊ/ + /i/ = we; /ʊ/ + /aʊ/ = wow). For /j/, the lips are retracted, and the tongue is positioned high and front (as in the vowel /ɪ/), and then the tongue glides toward the vowel that follows (e.g., /ɪ/ + /ɛs/ = yes; /ɪ/ + /u/ = you). Like diphthongs, there is limited vocal tract obstruction during production of glides. We know that diphthongs can be challenging for many children with CAS, so it follows that glides also would be challenging for some children with CAS.

Development of Vowels The development of vowels in the first 4 years of life is driven, in part, by anatomy (Kent, 1992). The size and shape of the oral cavity are different in infants and young children than in adults, and these differences impact the attainment of vowels. Kent describes the devel-

5.  Establishing Vowel Accuracy and Natural Prosody   207

Table 5–1.  Vowel Classifications and Corresponding Sample Words  Vowel Type With Phonetic Symbol

Sample Words

Pure Vowels

Vowel Type With Phonetic Symbol

Sample Words

Diphthongs

/i/

beet, sea, eat

/a͡ɪ/

right, item, why

/ɪ/

hit, middle, in

/a͡ʊ/

brown, out, now

/e/ or /e͡ɪ/

paint, weigh, ate

/ɔ͡ɪ/

boil, enjoy, toys

/ɛ/

penny, went, end

Rhotic Diphthongs and Triphthongs

/æ/

saddle, laugh, and

/ɪ͡ɚ/

steered, ear, pier

/u/

cool, losing, new

/ɛ͡ɚ/

stairs, air, dare

/ʊ/

shook, would, woman

/ʊ͡ɚ/

tour, pure, cure

/o/ or /o͡ʊ/

boat, open, no

/ɔ͡ɚ/

forty, or, door

/ɔ/

shawl, lost, raw

/ɑ͡ɚ/

party, are, far

/ɑ/

hot, rocket, father

/a͡ɪɚ/

fire, retired, liar

/ʌ/

come, up, above

/a͡ʊɚ/

hour, flower, sour

/ə/

above, banana, zebra

/ɔ͡ɪɚ/

foyer, lawyer, employer

/ɝ/

bird, furnace, heard

/ɚ/

mother, camper, refrigerator

opment of vowels in children up to 4 years of age. In the first year of life, the most frequent vocalizations are low front, low back, and central vowel-like vocants. Though not true vowels, these vocants resemble /ɛ/, /æ/, /ɑ/, /ə/, and /ʌ/. Around age 1 year, children are beginning to produce more adult-like vowels. Stages of mastery of vowels in early development are summarized in Table 5–2. Although there is individual variation of vowel acquisition (Kent & Rountrey, 2020), this table can help guide target utterance selection when addressing vowels in treatment.

Assessment of Vowels To adequately assess vowels, it is important for clinicians to develop strong skills in their own ability to discriminate vowels and recognize vowel deviations in children with whom they work. Gibbon (2013) describes the importance of strong vowel perception and production skills in clinicians who treat vowel disorders in children, as well as the ability to assess and analyze vowel production and generate appropriate goals and treatment strategies. Because vowel discrimination can be challenging, even for some seasoned clinicians, Strand and McCauley (2019) provide practice in assessment and analysis of vowel accuracy in the online companion videos that accompany the Dynamic Evaluation of Motor Speech Skills (DEMSS).

208   Here’s How to Treat Childhood Apraxia of Speech

Table 5–2.  Acquisition of Vowel Development in Children Age

Vowels Acquired

By 1 year

Child produces low front, low back, and central vocants (similar to /ɛ/, /æ/, /ɑ/, /ə/, and /ʌ/)

By 2 years

Child has acquired tense corner vowels /i/, /u/, /ɑ/; tense back vowel /o/; and lax central vowels /ə/ and /ʌ/

By 3 years

Child adds lax mid vowels /ɛ/ and /ɔ/ and diphthongs /aɪ/, /ɔɪ/, and /aʊ/

By 4 years

Child adds lax front vowels /ɪ/ and /æ/, tense front vowel /e/, and lax back vowel /ʊ/

After 4 years

Rhotic vowels /ɝ/ and /ɚ/ emerge

Note.  Based on “The Biology of Phonological Development,” by R. D. Kent, 1992, in Phonological development: Models, research, implications, by C. A. Ferguson, L. Menn, and C. Stoel-Gammon (Ed.), pp. 65–90. Copyright 1992 by York Press.

It is important to assess vowels in a variety of phonetic contexts to capture the child’s variability of productions in different contexts. Gibbon (2009) recommends assessing vowels by analyzing productions in a child’s speech samples; the findings should be analyzed in several ways, including the following: • Independent analysis — Make a list of each of the vowels the child can produce; this is the child’s vowel inventory. • Relational analysis — Identify the vowel errors including substitutions, distortions, and omissions. Describe how the child’s vowel productions compare to the expected adult productions; this is the child’s vowel error inventory. • Variability — Describe any tendencies for increased errors in utterances of increased length or in more phonetically complex words. Note any token-to-token inconsistency, that is, vowels produced differently in repeated productions of utterances. • Facilitating contexts — Describe “the effect of surrounding consonants on vowel accuracy” (p. 150) (e.g., /i/ may be more accurate if preceded or followed by an alveolar consonant; /u/ may be more accurate if preceded or followed by a velar consonant). • Stimulability testing — Determine which vowels may be potential targets by checking on the vowels for which the child is stimulable. Although transcription and analysis of vowels in connected speech samples may be ideal, for children who are highly unintelligible it may be difficult to identify the target words the child is saying. In this case, formal tests will be beneficial. Some formal motor speech assessments include analysis of vowel accuracy. Motor speech assessments that examine vowel accuracy are as follows. More detailed information about these tests can be found in Chapter 2. • Dynamic Evaluation of Motor Speech Skills (DEMSS; 2019) • Kaufman Speech Praxis Test for Children (KSPT; 1995) • Verbal Motor Production Assessment for Children, Revised Edition (VMPAC-R; 2021)

5.  Establishing Vowel Accuracy and Natural Prosody   209

Some articulation/phonology assessments also include a vowel examination portion, including Arizona Articulation Proficiency Scale, 4th ed. (AAPS-4; Fudala & Stegall, 2017) and the Diagnostic Evaluation of Articulation and Phonology: Articulation Assessment (DEAP; Dodd et al., 2006). These are described in greater detail in Chapter 2 on assessment.

Facilitating Accurate Production of Vowels When working with children with CAS, close attention to vowel production is essential. Gibbon and Mackenzie Beck (2002) suggest that to determine the proper approach to treatment of disordered vowels, an identification of the cause(s) of the vowel disorder needs to occur. Gibbon and Beck describe three possible factors influencing vowel production errors in children with articulation disorders: • auditory perceptual challenges (related to hearing loss or significant auditory discrimination difficulties) • cognitive/linguistic challenges (related to phonological disorders) • motor/articulatory challenges (related to CAS) Because CAS implies challenges with motor planning and programming, motor-based treatment approaches would be applicable for addressing the needs of children with distorted vowels and reduced vowel inventories. Motor-based treatment approaches should incorporate multisensory cueing, attention to rate, and careful selection of target utterances. The findings by Maassen et al. (2003) and Ingram et al. (2019) that children with CAS had significantly greater difficulty with vowel identification and discrimination suggest that a combined auditory/motor approach to vowel treatment may be beneficial for at least some children with CAS. Following are suggestions for facilitating accurate vowel production in treatment.

Address Vowels Early in the Process of Treatment Speech-language pathologists (SLPs) working with children with developmental articulation disorders and phonological disorders are not accustomed to giving much consideration to vowels because the challenges for these children tend to occur in the production of the consonant phonemes. Given the impact of correct vowel production on speech intelligibility, however, it is important to work on accurate vowel production right from the start. For children struggling to connect consonants and vowels to form CV or VC syllables, begin by working on increasing vocalizations and sound play. As children begin to imitate, you can work on meaningful vowels, such as /i, e, ɑ, ɔ, ʌ, o, u, aʊ/ in isolation before moving quickly to CV and VC syllables. Table 5–3 provides recommendations for addressing these isolated vowels in meaningful contexts. The Nuffield Centre Dyspraxia Programme, Third Edition (NDP3), provides pictures that represent each phoneme, including vowels (Williams & Stephens, 2010). Examples include a monkey for /ʊ/, a fish for /o/, a windy cloud for /u/, and a mouse for /i/. NDP3 provides practice at the isolated phoneme level for children who struggle to combine consonants and vowels before moving to production of alternating sequences such as /i, u, i, u, i, u/ and then to CV and VC words.

210   Here’s How to Treat Childhood Apraxia of Speech

Table 5–3.  Isolated Vowels Practice Activities Target Vowel /i/

Recommended Activity • Isolated /i/ • Child produces the /i/ vowels while singing E-I-E-I-O in the Old MacDonald song at a reduced rate. • Produce prolonged /i/ with pitch fluctuations while making emergency vehicle noises during car play activities.

• Repeated /i i i i/ • Produce repeated /i i i i/ while pretending to be a monkey.

/e/

• Produce prolonged /e/ as a sound of cheer during “car race” or other activities. • Produce /e/ to name the letter “a.”

/ɑ/

• Isolated /ɑ/ • Produce /ɑ/ after giving the dolls drinks of milk. • Produce /ɑ/ while “checking” the puppets during doctor or dentist play activity. • Produce /ɑ/ after smelling the flowers you planted in your pretend garden.

• Repeated /ɑ ɑ ɑ ɑ ɑ ɑ ɑ ɑ ɑ ɑ/ • Sing If All the Raindrops song

/ɔ/

• Produce prolonged /ɔ/ to denote. • Sympathy for an animal or doll that gets “hurt” • Something is “cute” (e.g., baby animals). • Disappointment about an event (e.g., a car did not make it all the way around a track)

/ʌ/

• Produce /ʌ/ for “uh oh” when crashing cars, pretending toy animals get “hurt,” etc. • Produce /ʌ/ while pretending to exert a great deal of effort (e.g., climbing up a mountain, banging a hammer while building a house).

/o/

• Child produces the /o/ vowel while singing E-I-E-I-O in the Old MacDonald song at a significantly reduced rate. • Child produces /o/ after the therapist produces /ʌ/ for “uh oh” when crashing cars, pretending toy animals get “hurt,” etc.

/u/

• Produce prolonged /u/ while pretending to be ghosts. • Produce /u/ to denote something that smells bad (e.g., skunk).

/aʊ/

• Produce /aʊ/ when the toy animals or dolls get “hurt” or as a funny sound when something falls or crashes.

5.  Establishing Vowel Accuracy and Natural Prosody   211

Choose Target Vowels Based on Stimulability and Normal Vowel Development When making treatment decisions about target utterance selection, consider the child’s stimulability for specific vowels, as well as what we know about normal development of vowels (referenced earlier in this chapter in Table 5–2). The vowel /ʌ/ is a good choice for early vowel practice. The vowels /i, u, o, ɑ/ also are early to develop and provide acoustic and motoric contrasts, as well as distinctive lip shapes, making them easier for children to learn. Because the vowels /i, u, o, ɑ/ are tense vowels, they can be taught in both closed syllables (those ending in a consonant sound) and open syllables (those ending in a vowel sound), so are excellent choices for teaching words with simple CV or CVCV syllable shapes such as me, do, go, mommy, and dada.

Use Monophthongs to Facilitate Production of Diphthongs and Semivowels (Glides) Many words common in young children’s vocabularies (e.g., hi, my, boy, toy, cow, wow, whee, you) contain diphthongs and glides. Like the early developing vowels described earlier, diphthongs can be produced in closed or open syllables, so target words with diphthongs can be practiced in CV shapes, making them good choices for early target utterances. When a child has learned early vowels, such as /i, ɑ, o, u/, begin working to elicit simple CV words with diphthongs and glides. Model the target words using a slower rate, and exaggerate the gliding manner between the two vowel elements. You can provide multisensory cues by using direct models or simultaneous productions, tactile cueing, phoneme placement cues, and hand gestures to facilitate accurate vowel production. Reduced rate during the early stages of learning also helps increase proprioceptive awareness, making the phonemes more salient for the learner. Once established, move right into functional phrases (e.g., Hi mom, I do, oh wow, my toy).

Facilitate Flexibility in Coarticulation Early in Treatment Children with CAS often demonstrate contextual limitations in phoneme sequencing. A child may be able to produce /o/ but only in a small number of phonetic contexts (e.g., no, go). Therefore, it is important to gradually begin to pair vowels with a wider range of consonants. First choose words with facilitating contexts to reinforce accurate vowel production, then try to increase flexibility by choosing consonants with varied place, manner, and voicing features (e.g., dough, bow, mow, show). Likewise, when a child has achieved production of a specific consonant but only is able to produce the consonant in a small number of vowel contexts (e.g., tea), gradually try to expand the child’s flexibility by choosing other vowels with varied tongue height, tongue advancement, and lip shaping (e.g., two, toe, tie, toy). Picture folders and mini-books are excellent resources for addressing flexible articulatory control of early syllable shapes and can be easily individualized for the needs of specific clients. Velleman (2003) recommends working on CV syllables during warm-up activities to expand coarticulatory flexibility using a “ba-ba” book or flip-book. These resources are described in the following sections.

212   Here’s How to Treat Childhood Apraxia of Speech

Picture Folders Picture folders provide children with opportunities to work on increased coarticulatory flexibility by practicing CV or VC syllables containing varied vowel and consonant phonemes during speech warm-up activities. Figures 5–3 and 5–4 illustrate sample CV picture folders. Picture folders are constructed using a piece of cardboard or a file folder with Velcro buttons to allow for flexibility in selecting and changing the picture targets. Pictures may be sorted in a variety of ways. In

Figure 5–3.  Sample CV picture folder for practicing /b/ with varied vowels.

5.  Establishing Vowel Accuracy and Natural Prosody   213

Figure 5–3, the pictures provide repetitive practice of the consonant /b/ with varied vowels. The pictures in Figure 5–4 provide repetitive practice of the /i/ vowel with varied consonants.

Mini Picture Books Small picture books are another resource for addressing early flexibility in coarticulation of CV or VC words. Separate books can be created for each targeted vowel with varied consonants or

Figure 5–4.  Sample CV picture folder for practicing the vowel /i/ with varied consonants.

214   Here’s How to Treat Childhood Apraxia of Speech

each targeted consonant with varied vowels. The target words from the books can be practiced during treatment sessions and can be sent home for additional practice. A picture book for the vowel /u/ may include these target words: Pooh, boo, moo, two, zoo, shoe, who, goo, new, and you, while a picture book for the consonant /m/ may include these target words: ma, me, moo, mow, more, my, May, aim, and em.

Syllable Flip-Books Syllable flip-books provide practice in production of CV words. The words are organized in groups of specific consonant phonemes plus a variety of vowels that, when combined, will form picturable words (e.g., bee, bay, ball, bah [sheep], bow [hair bow], boo [ghost], boy, bye, bow [to an audience]). As Figure 5–5 and 5–6 illustrate, multiples of the same pictures are set side by side. In that way, each syllable could be practiced repetitively in two or three picture

Figure 5–5.  Example of repetitive syllable practice using a CV syllable flip-book.

Figure 5–6.  Example of varied syllable practice using a CV syllable flip-book.

5.  Establishing Vowel Accuracy and Natural Prosody   215

sets (e.g., da, da; bah, bah, bah), or the pages could be flipped so different words could be practiced alternately using the same consonants (e.g., ma, me; bah, bow, boo) or varied consonants (e.g., bah, no, me). Syllable flip-books can be homemade and sent home with the child for practice. A commercially produced syllable flip-book, Word FLiPS for Learning Intelligible Production of Speech is available through Super Duper Publications. These types of flip-books provide opportunities to combine syllables for work on CVCV or CVCVCV words by combining pictures to form true words, such as • reduplicated CVCV (e.g., boo + boo for boo-boo) • consonant harmonized CVCV (e.g., bah + bee for Bobby) • vowel harmonized CVCV (e.g., tea + knee for teeny) • variegated CVCV (e.g., moo + V for movie) • CVCVCV (e.g., toe + May + toe for tomato) To create your own syllable flip-book, use a rectangular spiral blank page notebook approximately 5.5″ × 8.5″, and cut each page so there are three separate flip pages per page. Affix a CV picture to each page, three of the same pictures in a row (e.g., bah, bah, bah; bow, bow, bow; bee, bee, bee). In this way, the child can practice three of the same CV syllables in a row or pages can be flipped to practice varied syllable combinations of either meaningful words (e.g., bow + knee = bony) or nonsense words (e.g., bah + bow + bee). Possible words for the syllable flip-books, picture folders, and mini picture books are listed next.

Word Lists for Picture Folders, Mini Picture Books, and Syllable Flip-Books Box 5–1 lists sample picturable CV words that can be used when creating picture folders, mini picture books, or flip-books. By combining two CV words, CVCV words and phrases can be created.

Multisensory Cueing and Feedback for Increased Vowel Accuracy The use of multisensory cues, as described in Chapter 3, is essential for achieving success in CAS treatment. The use of auditory, visual, tactile, and metacognitive cues in treatment of vowels is described next.

Tips for Auditory and Visual Cueing • Positioning.  Sit facing the child, so the child has a clear view of your oral-facial structures. Try to position yourself at the same eye level as the child. • Rate.  During early practice, model the target utterances using a slower rate and prolong the target vowels to bring the vowels to the attention of the child. Gradually increase the rate to normal as the child’s articulatory accuracy increases. • Establishing initial articulatory configurations.  Strand (2020) recommends modeling and helping the child assume the initial articulatory configuration (correct lip shaping and jaw height) for the target word with attention to the upcoming vowel. For example, if the target is me, the lips would be closed and slightly retracted, and the jaw would be

216   Here’s How to Treat Childhood Apraxia of Speech

Box 5–1.  Sample Target Words for Picture Folders, Mini Picture Books, and Syllable Flip-Books CV Words /b/ bee, bah, boo, bow (for hair or gift), ball (w/out regard to final /l/), bay, bye, bow (to an audience), boy, burr, bear /p/ pea, pa, Pooh, paw, pay, pie, pow, purr /m/ me, ma, moo, mow, May, my, meow, more /w/ whee, wah (crying baby), whoa, way, woo, why, wow, whir /d/ D, da, dough, day, deer, door /t/ tea, two, toe, tie, toy /n/ knee, new, no, neigh, nigh /l/ la, low, lay /s/ see, sew, saw, say, sir /z/ Z, zoo /f/ fee, fo, foo, fi, fur /v/ V /ʃ/ she, shoe, show, shy /tʃ/ chew, chai, chow /dʒ/ G, jaw, J /j/ you, yay, yeah /r/ rah, row, rye /k/ key, K, cow, caw, coo /g/ goo, go, guy, grr (growling bear) /h/ he, ha, who, hoe, hay, hi, how, her CVCV Words and Phrases Words:  boo-boo, bye-bye, bah bah, papa, mama, moo moo, dada, tutu, no no, neigh neigh, nigh nigh, la la, ha ha, ho ho, hoo hoo, Bobby, baby, paper, mommy, daddy (da + D), saucer, see-saw genie, kiwi, teeny, teepee, before, below, body, bony, cargo, gopher, hero, honey, lady, lazy, movie, maybe, navy, puma, potty, tiny, today, shiny, wavy, wiper, whiny, zero, cowboy Phrases:  bye bear, bye boy, car key, fee fi, fi fo, guy go, my ma, hi guy, bye guy, see me, my guy, hi boy, hi ma, hi da, hi bear, hi sir, hi cow, bye ma, bye da, bye sir, bye cow, see cow, see ball, my dough, my knee, my ball, my shoe, tie shoe, tie bow, no way, no sir, no bear, no cow, ma go, da go, we go, cow go

high. For boo, the lips would be closed and rounded, and the jaw would be high. If you are not sure what the initial articulatory configuration would be, simply say the target utterance aloud to yourself while looking at yourself in the mirror or place your fingers near your lips and jaw to see and feel the movement gestures. Notice how the shaping of the lips and the height of the jaw often are more dependent on the shape of the upcoming vowel than the initial consonant phoneme.

5.  Establishing Vowel Accuracy and Natural Prosody   217

• Natural modeling.  Be sure to model vowels accurately. Say the target words aloud to yourself in a natural way, and determine if any vowels are shortened or produced as a schwa /ə/ (e.g., believe would be modeled as [bə.ˈliv], not [bi.ˈliv] and button would be modeled as [ˈbʌ.ɾn̩], with a syllabic /n̩/, not [ˈbʌ.tɪn]). • Stressed syllables in multisyllabic words.  When working on words with two or more syllables, Gibbon and Mackenzie Beck (2002) recommend choosing words in which the target vowel is in a stressed syllable of the word, as the acoustic and proprioceptive information will be stronger. For example, in the words table, mistake, and vacation, the /e/ vowel is in the stressed syllable, whereas the /e/ in Monday is in the weak syllable and would be a less desirable target for addressing /e/. As the child’s productions improve, targets also can include words with the target vowels in unstressed syllables. • Auditory feedback.  Provide auditory feedback by recording and replaying the child’s productions so the child can make judgments about accuracy of production. Portable phones and tablet computers offer reasonably good microphones to record and play back the child’s productions. • Visual feedback. • Use mirrors when facilitating lip rounding or retraction or when helping establish appropriate jaw height. • VowelViz and VowelViz Pro are apps by CompleteSpeech (https://completespeech. com/vowelvizpro/) that allow the child to see where their vowel production falls on a vowel quadrilateral. VowelViz ($19.99) provides a basic vowel quadrilateral display, including /ɝ/, and VowelViz Pro ($49.99) comes with pictured flashcards for all monophthongs and rhotic vowels and a variety of background themes (e.g., outer space, flowers, pirates) to sustain the child’s interest in the activity.

• Ultrasound biofeedback.  Ultrasound biofeedback can be particularly useful with rhotic vowels and diphthongs. It is the only technology currently available to SLPs to help the user see the tongue root retraction needed for a good rhotic quality. For diphthongs, the user can observe the gliding of the tongue from one position to another. When working on vowels in neighboring vowel spaces, such as /i/ and /ɪ/, ultrasound biofeedback may not be as useful because the visual difference in tongue position is so subtle. See Chapter 4 for more detailed information regarding using ultrasound biofeedback in therapy for older children.

Tips for Tactile Cueing Tactile cues can be quite beneficial for helping the child achieve jaw stability, correct jaw height, and appropriate degrees of lip rounding and lip retraction during vowel production. • Programs that incorporate tactile cues.  Tactile cues can help the child stabilize the jaw, facilitate grading of jaw height, inhibit jaw sliding, and achieve lip rounding and retraction. Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT)– trained clinicians are familiar with the use of specific prompts to support correct vowel production and movement between phonemes. Other treatment approaches, including Dynamic Temporal and Tactile Cueing (DTTC) and Motor Speech Treatment

218   Here’s How to Treat Childhood Apraxia of Speech

Protocol also incorporate tactile cues into treatment. See Chapter 4 for more detailed information about these treatment programs. • Reduce overexaggerated movements.  Keep in mind that children start off using greater jaw excursion than adults. During treatment, you may need to model movements that are more exaggerated than typical adult productions to support the child’s ability to recognize differences in lip shaping and vowel height. However, we want to resist training overexaggerated lip and jaw movements for vowels by helping the child achieve more natural degrees of movement necessary for accurate vowel production. Place your fingers under the child’s chin to help the child achieve the correct amount of jaw opening for the vowel and to inhibit overexaggerated jaw movements. Place your fingers at the corners of the child’s lips to help facilitate just the right amount of lip rounding for /u/, /ʊ/, /o/, and /ɔ/ and lip retraction for /i/, keeping in mind that the accurate amount of jaw lowering and lip rounding/retraction is not static and will vary depending on the surrounding phonemes.

Tips for Metacognitive Cueing There are many literacy programs that include metacognitive cueing for vowels. The Lindamood Phoneme Sequencing Program for Reading, Spelling, and Speech (LiPS; Lindamood & Lindamood, 2011) is an example of one of these programs. When explaining the vowels to the child, they implement a vowel circle that illustrates how the vowels compare to each other in terms of lip retraction and rounding, jaw opening, and tongue position. The child is encouraged to explore the placement of the articulators to figure out where each vowel belongs on a vowel circle (actually a U shape). The order of the vowels is as follows /i, ɪ, ɛ, e, æ, ʌ, ɑ, ɔ, o, ʊ, u/. The vowels are put into three categories, smile vowels /i, ɪ, ɛ, e, æ, ʌ/, open vowels /ɑ, ɔ/, and round vowels /o, ʊ, u/, in which there is a corresponding picture of the mouth for each category. Children are continually encouraged to note the position of their lips, jaw, and tongue as they go through the vowels. Encourage the child to place their fingertip near their teeth for a smile vowel (e.g., /i/) and for a more open vowel (e.g., /æ/) to bring their attention to the contrast in jaw opening between the two vowels. Diphthongs are referred to as “sliders,” as the child moves from one position to the next (e.g., /aɪ, aʊ, ɔɪ/). The movement transition can be drawn with the finger on the vowel circle or vowel quadrilateral to go along with the corresponding movement of the articulators. The interactive materials are utilized in a manner for the child to be an interactive problem solver in the process of determining which vowel goes where. Rhotic vowels are referred to as the “r-controlled vowels” /ɝ, ɔɚ, ɑɚ/, and it is explained how the /r/ following the vowel will change the vowel. Another example of a program that uses metacognitive cueing is Phonic Faces (Norris, 2003). In Phonic Faces, the grapheme is written on a character’s face in a manner that shows how the sound is made or provides mnemonic visualization, such as a pair of eyeglasses on the character that represents /aɪ/. In addition, the vowels are presented in tense-lax pairs for each grapheme. Adult characters are used for the long vowels (e.g., /i, e, aɪ, u, o/), and images of babies are used for the short vowels (e.g., /ɛ, æ, ɪ, ɑ/). Figure 5–7 provides an example. In addition, each vowel pair has a story that helps the child remember what the vowel sound is and how it is produced. For example, the character Amy Ann is used for /æ/. She cries a lot using this sound. This helps the child remember that they need to open the mouth a bit more for this sound in a fun interactive way, which is often appealing to younger children.

5.  Establishing Vowel Accuracy and Natural Prosody   219

Figure 5–7.  Phonic Faces representing the characters for /e, i, aɪ, o/ on the top row and /æ, ɛ, ɪ, ɑ/ on the bottom row. (From Phonic Faces, 2003, by Jan Norris. Used by permission of author.)

Use Minimal Pairs to Establish Vowel Distinctions Children who struggle with vowel substitutions, such as individuals who substitute the tense vowel /i/ for the lax vowel /ɪ/ (e.g., the child produces “meat” for mitt), may benefit from working on minimal pairs. When working on minimal pairs, the child needs to change the articulatory movements to make meaningful semantic distinctions. Paired words that compare the target vowel and the contrast vowel are used as stimuli. Before working on production activities, be sure to evaluate the child’s ability to discriminate between the target vowel and the contrast vowel and work on auditory discrimination as needed. Box 5–2 provides a few suggestions of minimal pairs activities for addressing vowel accuracy. Box 5–2.  Minimal Pairs Activities for Vowels 1. Make two sets of paired pictures/words that vary only by the vowel (e.g., /i/ and /ɪ/ — deep/ dip, feet/fit, green/grin, sheep/ship; /æ/ and /ɑ/ — ax/ox, black/block, hat/hot, tap/top; /e/ and /ɛ/ — braid/bread, gate/get, mane/men, rake/wreck). The child chooses and names a picture, and the partner shows the picture the child said. If the child was correct, the pictures will match; if not, the pictures will not match, and the child will know to change the movement to achieve a more accurate production. 2. Practice minimal pairs by alternating between the paired words (e.g., meat, mitt, meat, mitt, meat, mitt) to develop better awareness of auditory and proprioceptive distinctions between the paired words. 3. Practice minimal pairs in triples, with words containing the target vowel in the first and third positions (e.g., mitt, meat, mitt; bin, bean, bin). 4. Produce sentences with both words of the minimal pair in the same sentence (e.g., “I caught the meat with my mitt mitt.” “I need a black block block.”).

220   Here’s How to Treat Childhood Apraxia of Speech

Practice With Vowel-Loaded Sentences and Stories As a child’s accuracy improves, the child can practice target vowels in vowel-loaded sentences, carrier phrases, and stories. In vowel-loaded sentences and carrier phrases, the target vowel will be practiced two or more times within a target utterance, as shown in Box 5–3. For nonreaders, pictures can be used to address specific vowels in carrier phrases. Figure 5–8 illustrates an example of carrier phrases to work on the /aɪ/ vowel. Stories that incorporate a set of target words using an “add-on” story technique may be helpful in facilitating the production of target vowels in a connected speech format. Printed Box 5–3.  Vowel-Loaded Sentences and Carrier Phrases Sample Sentences with Two or More Target Vowels /ʊ/ “He took a look at the book book.” /ɪ / “Where did you put it it?” /æ/ “The cat is wearing a hat hat.” /o/ “Let’s go back home home.” Target Vowel /ɪ/ With Carrier Phrase — Did you see the ___? “Did Did you see the pig pig?” “Did Did you see the hill hill?” “Did Did you see the mitten mitten?” “Did Did you see the zipper zipper?”

Figure 5–8.  Pictures to elicit carrier phrases for /aɪ/ practice.

5.  Establishing Vowel Accuracy and Natural Prosody   221

words or pictures denoting target words are incorporated into a story that is created by the child along with an adult or peer partner. The stories can be silly but should allow for practice of the target vowel in a connected sentence activity. For the /e/ vowel, a story could be: “A snake woke up one morning and put on his cape cape. He was almost late for the big game game. The snake headed over to the lake to play water polo with Jake. All of the sudden, Jake sprayed water on the snake Jake snake, and the ref sent Jake to jail jail.” Most of the words in the sample story and previous sentences are content words. As discussed later in this chapter, content words tend to receive greater relative stress than function words in sentences. Words with greater relative stress may be preferable during initial stages of practice for children with motor speech disorders working on vowels because vowels in stressed syllables are longer in duration relative to surrounding syllables, offering greater auditory and proprioceptive feedback.

Establishing Natural Prosody Difficulty with prosody is cited frequently as a challenge for children with CAS (Davis et al., 1998; Shriberg et al., 1997). Children with CAS often exhibit excess-equal stress, misplaced stress, syllable segregation, and a slow rate of speech, resulting in monotonous or atypical-sounding speech. Although prosody typically falls under the umbrella of phonology, Gerken and McGregor (1998) suggest that prosody also interacts with and impacts the language systems of syntax and pragmatics. This chapter focuses on understanding these features of prosody and facilitating development of improved prosody in children with CAS: • stress:  the relative emphasis given to a certain syllable in a word or a certain word in a phrase or sentence • intonation:  variations in pitch that signal the differences between statements and different types of questions; often these pitch changes are used in connection with stress to give emphasis to certain syllables or words in sentences • rhythm:  the time intervals between words in connected speech and the timing of stress in sentences • chunking:  the grouping of syntactic units between pauses • tone of voice:  vocal changes that convey the feelings and mood of the speaker, or denote sarcasm and irony

Features of Prosody It is important to understand the role of prosody in communication. A child who struggles with prosody will sound unnatural to the listener, even if the segmental and phonotactic features of their speech have improved. The child’s speech may have a robotic quality, impacting semantics and syntax. It also may be difficult for the child to match their tone of voice with the mood or feeling they are trying to convey, impacting pragmatic language. Prosodic features are described in greater detail in the following sections. Later in the chapter, suggested treatment strategies to facilitate better prosody in children with CAS are described.

222   Here’s How to Treat Childhood Apraxia of Speech

Stress The use of “inappropriate prosody, especially in the realization of lexical or phrasal stress” (ASHA, 2007, p. 4) is a feature commonly associated with CAS. Excessive equal stress, when most or all the syllables in a word or utterance receive pronounced stress, was the most frequently observed prosodic characteristic of children with suspected CAS (Shriberg et al., 1997). Munson et al. (2003) found that children with CAS were able to produce distinctions between stressed and weak syllables, but the distinctions were subtle and were not consistently recognized perceptually by listeners. The two types of stress discussed in this chapter are lexical stress and sentence stress. Lexical stress refers to word-level stress, in which greater relative stress is placed on a specific syllable or syllables within a word. Words containing more than one syllable, with the exception of some compound words, have both stressed and weak syllables. In the word mo mommy, the first syllable is stressed (S), and the second syllable is weak (w) and has a “Sw” stress pattern. In the word again gain, the second syllable has greater relative stress and has a “wS” stress pattern. The pronunciation and stress assignment of some words with identical spellings will change depending on whether the word is a noun or a verb. Consider the words in Table 5–4 and note how the word meaning changes depending on the placement of syllable stress with nouns receiving stress on Syllable 1 and verbs on Syllable 2, illustrating how semantics and syntax influence lexical stress. Sentence stress refers to both phrasal stress and contrastive stress. Phrasal stress describes the natural stress of a specified language. In English, phrasal stress is marked by applying greater relative stress to content words (nouns, verbs, adjectives, some adverbs) than function words (prepositions, conjunctions, articles, pronouns). In the sentence, “I was walk walking to the park with my BRO BROther on Sun Sunday,” greater relative stress would be applied to the underlined words or syllables, and the strongest stress would occur on the first syllable in the word brother. Contrastive stress refers to application of stronger stress to a specified word in a sentence and often is used for clarification or emphasis. Unlike phrasal stress, contrastive stress may be applied to any word in a sentence, not just content words. Consider the use of contrastive stress for clarification in this conversation: Bob:  “I went to the park with Maya’s brother on Sunday.” Jim:  “Oh, I didn’t know you had a brother.” Bob:  “Not my brother; Maya’s brother.” Contrastive stress often is used to apply emphasis to certain words in connected speech as in these examples: “MY turn.” “I’m SO excited!” “That is NOT my ball.” “I want the BLUE marker.” Peña-Brooks and Hegde (2007) describe three acoustic features that distinguish stressed syllables from unstressed syllables. These three features — increased loudness, increased duration, and higher pitch — give a stressed syllable greater prominence than the surrounding syllables. The stressed syllables are produced with greater relative vocal intensity (loudness)

5.  Establishing Vowel Accuracy and Natural Prosody   223

Table 5–4.  Lexical Stress Contrasts in Noun-Verb Heteronyms NOUNS

VERBS

conduct con

conduct duct

attribute

attri ttribute

con contest

contest test

escort

escort scort

sub subject

subject ject

object ob

object ject

per permit

permit mit

re record

record cord

and longer relative duration than the surrounding unstressed syllables. In addition, a stressed syllable often is produced with a higher pitch than the neighboring unstressed syllables. For the speaker to vary the loudness, duration, and pitch of a syllable, motoric adjustments are made in the programming of some spatiotemporal parameters of speech movements, including expelling more air from the lungs, sustaining the duration of the vowel for a longer time frame, and vibrating the vocal folds more rapidly during production of stressed syllables. These subtle motoric variations can be quite challenging for children with CAS.

Intonation Intonation in English is bound to grammar. Rising and falling pitch patterns are associated with different sentence types. Falling intonation, marked by a fall in pitch at the end of a sentence, is commonly used when producing declarative sentences and “wh” questions. When producing “yes-no” questions or tag questions, rising intonation, where the speaker’s pitch rises at the end of the sentence, is used. Consider the dialogue in Box 5–4. The arrows at the end of each sentence indicate falling  or rising  intonation. Box 5–4.  Dialogue Illustrating Falling and Rising Intonation Child:  Jenny and I are going to the mall after school.  Parent:  You mean after you do your homework, right?  Child:  I knew you were going to say that.  Parent:  How are you getting there?  Child:  We’re taking the bus.  Is that okay?  Parent:  That’s fine.  What time will you be home?  Child:  I thought maybe we could eat dinner there?  Parent:  That’s fine.  Just be sure you’re home by 8:00. 

224   Here’s How to Treat Childhood Apraxia of Speech

Rhythm The English language is a stress-timed language, in which stressed syllables occur at relatively regular intervals regardless of the number of unstressed syllables occurring between each pair of stressed syllables. The unstressed syllables are lengthened or shortened to accommodate these regular intervals of stress. In the first sentence of Table 5–5, stress is placed on the content words (in bold), and the rhythm of the stressed syllables occurs at fairly regular time intervals. Notice that the duration of stressed words/syllables is longer than those not receiving stress. In the second sentence, the words “to his old” would be spoken more quickly to maintain the rhythmic interval. Phoneme omissions will help accommodate the more rapid production of that phrase. Children who use excessive equal stress will struggle with the rhythmicity of their language. It should be noted that children 5 years of age are still refining this pattern of rhythm in stress-timed languages such as English (Post & Payne, 2018, as cited in Kent & Rountrey, 2020). Thus, addressing the feature of rhythm would not be appropriate in a preschool-age child but would be more appropriate for a school-age or older child.

Chunking Chunking refers to the grouping of syntactic or semantic units, followed by brief pauses in connected speech. Pauses serve several functions. Pauses are inserted at natural phrase breaks, when naming items in a list, or when trying to establish subtle differences in meaning. Natural phrase breaks are used in longer sentences (e.g., Mommy stopped at the grocery store / to buy some milk / before she took me to school.) We often pause between words in a list as an accommodation to the listener (e.g., I invited Jesse, / Rocky, / Max, / Malcolm, / Hank, / and Sammy to my party.). Pauses also are required to establish meaning differences in sentences. The sentence pairs in Box 5–5 illustrate how important chunking and pausing are to establish differences in meaning.

Tone of Voice Achieving variations in tone of voice requires manipulation of a motoric aspect of speech (vocal quality, rate, pitch, rhythm, intensity) to express different moods or feelings, as well as to denote sarcasm and irony. Struggles with variations in tone of voice will impact children’s pragmatic language. To summarize, the five features of prosody described have their roots in difficulty with motor speech planning and programming. The impacts are widespread across multiple areas of speech and language. Table 5–6 summarizes the underlying deficits and impacts of prosody challenges in children with CAS. Table 5–5.  Rhythm in a Stress Timed Language The ðʌ

boy  bɔɪ 

is  ɪz

walking wɔ.kɪŋ

to tu

school. skul

The  ðʌ

boy bɔɪ

is ɪz

walking wɔ.kɪŋ

to his old  tu ɪz ol

school. skul

5.  Establishing Vowel Accuracy and Natural Prosody   225

Table 5–6.  Summarization of the Underlying Deficits and Impacts of Prosody Disturbances Areas of Challenge

Underlying Planning/Programming and Other Deficits

Impacts on Communication

Stress

DIFFICULTY PLANNING AND PROGRAMMING:  Speech breathing muscles to achieve variations in loudness and phoneme duration; laryngeal muscles to vary vocal pitch

Speech Semantics Syntax Pragmatics

Intonation

DIFFICULTY PLANNING AND PROGRAMMING:  Laryngeal muscles to vary vocal pitch

Speech

Rhythm

DIFFICULTY PLANNING AND PROGRAMMING:  Laryngeal muscles to vary vocal pitch; speech breathing muscles to achieve variations in vocal loudness and phoneme duration

Speech Pragmatics

Chunking

DIFFICULTY PLANNING AND PROGRAMMING:  Speech breathing muscles to modulate number of words spoken on a breath and duration of pauses between phrases DIFFICULTY WITH:  Self-monitoring

Speech Syntax

Tone of voice

DIFFICULTY PLANNING AND PROGRAMMING:  Laryngeal muscles to modulate voice quality, pitch, and vowel duration; velopharyngeal muscles to modulate resonance; articulatory muscles to modify rate of speech

Pragmatics

Box 5–5. Pauses in Sentences That Clarify Differences in Meaning My uncle, / the astronaut, / and my Dad took me to the aquarium. My uncle, the astronaut, / and my Dad took me to the aquarium. I said to him, / “Today we will get it done.” I said to him today, / “We will get it done.” I want chicken, / soup, / and milk. I want chicken soup, / and milk. And the classic meme Let’s eat, / Grandma. Let’s eat Grandma.

Assessment of Prosody Prosody assessment will depend on the child’s age, the nature of the child’s prosodic features during spontaneous speech, and the impact of prosody on the child’s language (semantics, syntax, pragmatics). Abbiati and Velleman (2021) suggest taking note of the child’s use of the features of prosody during spontaneous speech and thinking critically about what you need to assess more specifically. Some formal tests, such as the DEMSS, score prosodic accuracy (wordlevel stress) for words with two or more syllables. The tasks described in Table 5–7 can be used to informally assess if the child is able to use the various features of prosody.

Table 5–7.  Informal Prosody Assessment Tasks PROSODIC FEATURES

INFORMAL ASSESSMENT TASKS

Lexical stress Ask the child to produce these words following a model in single words or in meaningful sentences (e.g., I stepped on a hard object. I object to these questions.)

Lexical stress

Can the child accurately apply contrasting lexical stress patterns? Sample stimuli: contrast contrast

address address

permit permit

conduct conduct

object object

record record

progress progress

envelope envelope

Can the child produce lexical stress patterns correctly in two- to four-syllable words?

Ask the child to repeat these words following a natural model (without over overemphasis on the stressed syllable). If the child’s lexical stress is incorrect or if the child produces equal stress, see if more emphatic stress models will facilitate correct stress assignment.

Sample stimuli:

Contrastive stress This task can be done imitatively or in response to questions (e.g., Who ate the apple? “The baby ate the apple.” What did the baby eat? “The baby ate the apple.”) Another option is to model the sentence and then ask a question with a word in error (e.g., Mom got new red shoes. Did dad get new red shoes? “No, mom got new red shoes.”)

daddy

newspaper

open

directions

water

banana

again

computer

today

remember

begin

exercising

police

television

forgot

community

radio

ingredients

triangle

invitation

cereal

Cinderella

Can the child shift the relative stress to different words in a sentence? Sample stimuli: The baby ate the apple. The baby ate the apple. Mom got new red shoes. Mom got new red shoes. Mom got new red shoes. He doesn’t like chocolate cake. He doesn’t like chocolate cake. He doesn’t like chocolate cake.

Intonation Model sentences with either rising or falling intonation at the end. See if the child can repeat the model with the correct intonation.

Does the child change pitch to denote different sentence types (e.g., declarative, yes/ no and wh- questions)? Sample stimuli: The baby ate the apple.  Did the baby eat the apple? 

226

Table 5–7.  continued PROSODIC FEATURES

INFORMAL ASSESSMENT TASKS

Intonation  continued

Sample stimuli:  continued He found his hat.  Did he find his hat?  What time is dinner?  Is dinner soon?  He can count to 100.  He can count to 100? 

Rhythm Ask the child to repeat sentences and note if the child uses rhythmic stress patterns. Keep in mind that children typically do not stabilize the use of timed stress patterns until approximately 7 years of age.

Is the child using a rhythmic stress pattern in sentences with greater stress applied to content words? Sample stimuli: Mom is making a salad for dinner. When is Tommy going home? He never brushes his hair. I saw her dog behind the bushes.

Chunking If the child’s speech intelligibility tends to decline in sentences, see if the child can chunk short phrases from the sentence and pause between these phrases to attain greater intelligibility. Write these sentences on sentence strips with marks to denote where the pause will be inserted and instruct the child to use chunking and pausing to achieve increased intelligibility.

Is the child able to chunk phrasal units of a sentence together separated by short pauses? Sample stimuli: She is walking // down the street. She is walking // down the street // to catch the bus. I went to the store // to buy some milk. I went to the store // to buy some milk // for breakfast tomorrow. He plays soccer on Tuesday, // Thursday, // and Saturday. I invited Jose, // his brother Jesse, // and Adam to the party.

Control of tone of voice, loudness, pitch Provide a list of short sentences and ask the child to produce the sentences with a specified emotion (perhaps explaining the situation), pitch, or loudness. Note if the child can vary these vocal features.

Can the child vary vocal quality, pitch, and loudness in sentences? Sample stimuli: I came in second place. (happy/excited) I came in second place. (sad/disappointed) I need to go to bed. (tired) I need to go to bed. (angry) I want more cookies. (childlike voice) I want more cookies. (dad voice) Hi mommy. (whispered) Hi mommy. (loud)

227

228   Here’s How to Treat Childhood Apraxia of Speech

Keep in mind that there can be wide variation in listeners’ judgments of children’s prosodic control, and listeners often perceive stress and intonation patterns as being inaccurate when they are not, especially when the speaker exhibits substantial speech sound errors (Skinder et al., 1999). Thus, it is imperative to hone your skills in listening to and making judgments about prosody. Audio recording assessments can be beneficial, so you can go back and listen again rather than trying to make judgments on the spot.

Treatment for Prosody To achieve appropriate prosody requires subtle manipulation of various motor speech variables to vary pitch, loudness, duration, and vocal quality. This can be challenging for children with CAS. Because prosody difficulties are common findings in children with CAS, it is recommended that work on prosody begin early in the treatment process (Strand & Skinder, 1999). There is no need to wait until a child is speaking in sentences before addressing certain elements of prosody, such as intonation, tone of voice, pitch, and loudness. Although SLPs are aware of prosody challenges existing in children with motor speech disorders and autism spectrum disorder, they are less comfortable assessing and treating prosody because they feel they lack knowledge and understanding of proper assessment and treatment techniques (Hawthorne & Fischer, 2020). The following section offers recommendations for supporting children who struggle with the use of stress, intonation, rhythm, chunking, and tone of voice. In addition to some of the strategies described, there are free and affordable digital tools available, such as the Waveform, Annotations, Spectrogram & Pitch (WASP) program (Huckvale, 2021), which can be downloaded or used as a web version (https://www.speechandhearing.net/laboratory/wasp/) and Voice Analyst: Pitch & Volume, an app designed for the iPad. WASP allows the speaker to record their or their client’s utterance and then see the acoustic correlates of prosody, which are amplitude (loudness), pitch, and duration. When playing the signal back, both the client and SLP can see and hear the production. In addition to being able to better visualize and measure prosodic characteristics, the SLP can also reinforce the concept of smooth coarticulation. The Voice Analyst: Pitch & Volume app provides the speaker real-time visual biofeedback of pitch and volume individually or combined on one screen. This is a simpler display than WASP, and you can set parameters for fundamental frequency and decibel level for the client to target or stay within the parameters of. For example, a child who uses a very quiet voice can be given a dB target to hit to be loud enough, and a child who is monotone can be coached to fill in a particular pitch range. See Figures 5–9A and B for further explanation of WASP and Voice Analyst, respectively.

How to Facilitate Appropriate Stress in Treatment Although most programs that address treatment of speech production typically do not address prosody, there are some programs that specifically address aspects of prosody. Rapid Syllable Transition Treatment (ReST; Murray et al., 2015) specifically addresses syllable stress assign-

5.  Establishing Vowel Accuracy and Natural Prosody   229

A

B Figure 5–9.  A. “Wanna play?” waveform, spectrogram, and intonation contour represented on WASP. B. “Wanna play?” dB and Hz contour on Voice Analyst.

ment and smooth coarticulatory transitions in treatment. DTTC (Strand, 2020) integrates work on variations in loudness, rate, stress, and tone of voice into treatment. Following are several considerations and activities to support the use of appropriate contrastive and lexical stress for children at various stages of development. During each of the activities described, appropriate stress should be modeled for the child during treatment, as modeling a staccato pattern of production or placing stress on the wrong syllable may encourage the child to use robotic speech or incorrect lexical stress placement. It can be easy to fall into habits of emphasizing a specific syllable of a word if that is the syllable with which the child is having trouble. For instance, if the target utterance is Hi mommy, and the child says, “Hi mama,” a therapist may be inclined to overemphasize the last syllable and model, “Hi mommy.” In this case, it would be more appropriate to use backward chaining, maintaining appropriate syllable stress throughout the process (e.g., Say “me.” Now say “mommy.” Now say “Hi mommy.”).

230   Here’s How to Treat Childhood Apraxia of Speech

Using Books to Work on Prosodic Variation Many books for young children provide opportunities to work on prosody (e.g., applying emphatic stress, varying loudness and duration, changing tone of voice). Good choices for early books are those that have few words, so the focus can be on variations in some suprasegmental aspect of speech. The following books offer opportunities to work on prosody. Box 5–6 provides examples of books to work on prosody. They can be worked on during treatment sessions and sent home with children to practice with their families.

Storybooks to Facilitate Emphatic Stress Classic repetitive line stories often lend themselves to modeling and practicing contrastive stress. Consider the lines, “Somebody’s been sitting on MY chair” from Goldilocks and the Three Bears; “‘Not I,’ said the cat,” from The Little Red Hen; or “I’ll huff, and I’ll puff, I’ll BLOW the house down,” from The Three Pigs, and “You can’t catch ME I’m the GINgerbread man.” from The Gingerbread Man. These lines all contain words where it would be appropriate to use emphatic stress.

Emphasize Key Words by Incorporating Emphatic Stress Even very early on in treatment, you can model and help the child increase the duration of vowels and increase vocal intensity in single words and on specific words in phrases and sentences. For younger children, modeling contrastive stress in words and short phrases with high levels of emotional content is beneficial. Some examples include “OOOH,” “AAAH,” “WOW,” “UH oh,” “WHEE,” That’s MINE,” “KaBOOM,” “I DID it,” “HooRAY.” Box 5–6.  Books for Young Children to Address Prosody Boynton, S. (1984). Doggies: A counting and barking book. Little Simon Publishing. Cook, J. (2014). Decibella and her 6-inch voice. Boys Town Press. Crum, S. (2016). Uh-oh! Knopf Books for Young Readers. Heim, A. (2020). Quiet down loud town. Clarion Books. LaRochelle, D. (2014). Moo! Bloomsbury USA. Munsch, R. (2020). Up, up, down. Scholastic Canada. Patricelli, L. (2003). Quiet loud. Candlewick Press. Patricelli, L. (2003). Yummy yucky. Candlewick Press. Patricelli, L. (2008). No no yes yes. Candlewick Press. Raschka, C. (2007). Yo! Yes? HMH Books for Young Readers. Shannon, D. (1998). No, David! Blue Sky Press. Sullivan, M. (2015). Ball. HMH Books for Young Readers. Tullet, H. (2017). Say zoop! Chronicle Books.

5.  Establishing Vowel Accuracy and Natural Prosody   231

Address Contrastive Stress Using Statement Question-Response (SQR) In the SQR exercise, the child is given a statement and then asked various questions about the statement. The word in the sentence requiring greater relative stress will change depending on the question being asked. For children who can read, an additional cue, such as a chip or block, can be placed on the word of the written sentence that will receive the greatest stress. Examples of SQR are shown in Box 5–7. When working to facilitate contrastive stress, multisensory cueing can be quite beneficial. Use accompanying hand gestures and facial expressions when modeling contrastive stress. Talk about how some words or parts of words are louder and longer than other words. Consider incorporating digital materials, such as WASP, into treatment to provide visual representations of the child’s production contours. These strategies will help encourage the child to use more robust variations in stress. In the example in Figure 5–10, WASP is used to provide a visual representation of the contrastive stress in the phrase, “The bird is red.” Note the rising contour and bigger sound wave for the words receiving greater relative stress.

Address Contrastive Stress Using a Fix-the-Sentence Exercise The fix-the-sentence format is similar to the preceding SQR exercise but without questions. The clinician reads a sentence and then repeats it, inserting an incorrect word. The child needs to repeat the original sentence, applying greater stress on the corrected word. Examples of the fix-the-sentence exercise are shown in Box 5–8. Box 5–7.  Example of SQR Exercise Statement:  “The bird is red.” QUESTION: “What color is the bird?” RESPONSE:  “The bird is RED.” QUESTION: “What is red?” RESPONSE: “The BIRD is red.” Statement:  “Mom hid the red shoes under the bed.” QUESTION: “Who hid the shoes under the bed?” RESPONSE: “MOM hid the red shoes under the bed.” QUESTION: “Which shoes did Mom hide under the bed?” RESPONSE:  “Mom hid the RED shoes under the bed.” QUESTION: “Where did Mom hide the red shoes?” RESPONSE:  “Mom hid the red shoes under the BED.” QUESTION: “What did Mom do with the red shoes?” RESPONSE: “Mom HID the red shoes under the bed.”

232   Here’s How to Treat Childhood Apraxia of Speech

Figure 5–10.  View of WASP2 spectrogram illustrating contrastive stress for production of sentences “The BIRD is red.” (on left) and “The bird is RED.” (on the right).

Box 5–8.  Example of Fix-the-Sentence Exercise Statement:  “Shyla ate chocolate ice cream.” INCORRECT SENTENCE:  “Sam ate chocolate ice cream.” RESPONSE: “No, SHYLA ate chocolate ice cream.” INCORRECT SENTENCE:  “Shyla ate strawberry ice cream.” RESPONSE:  “No, Shyla ate CHOCOLATE ice cream.” INCORRECT SENTENCE:  “Shyla ate chocolate cake.” RESPONSE:  “No, Shyla ate chocolate ICE CREAM.” Statement:  “Mario likes fishing at grandpa’s pond.” INCORRECT SENTENCE:  “Julio likes fishing at Grandpa’s pond.” RESPONSE: “No, MARIO likes fishing at Grandpa’s pond.” INCORRECT SENTENCE:  “Mario likes swimming at Grandpa’s pond.” RESPONSE:  “No, Mario likes FISHING at Grandpa’s pond.” INCORRECT SENTENCE:  “Mario likes fishing at his uncle’s pond.” RESPONSE:  “No, Mario likes fishing at GRANDPA’S pond.” INCORRECT SENTENCE:  “Mario likes fishing at Grandpa’s river.” RESPONSE:  “No, Mario likes fishing at Grandpa’s POND.”

5.  Establishing Vowel Accuracy and Natural Prosody   233

Use Guessing Activities to Support Use of Contrastive Stress The make-a-guess activities allow for opportunities to practice using contrastive stress. Each participant attempts to guess or make a prediction. Emphatic stress is incorporated into sentences when making a guess and when evaluating the guess or prediction. Following are examples of using contrastive stress during guessing activities. Example 1.  Reading a Flap Book Activity:  While reading a flap book, the student is asked to guess what is hidden behind the flaps. The guess:  “I think it’s a PUPPY.” If incorrect:  “It’s NOT a puppy. It’s a DUCK.” If correct:  “It IS a puppy.” Example 2.  Searching for Hidden Objects The guess:  “I think it’s under the TABLE.” The child searches the named location. If incorrect:  “It’s NOT under the table. Maybe it’s under the CHAIR.” The child searches the new location. If correct:  “It IS under the chair.” Example 3.  Predicting What Will Happen First Activity:  The child and clinician each guess which of two feathers or balloons will land on the ground first or which race car or wind-up toy will reach the finish line first. The guess:  Child — “I think the RED car will win.” Clinician — “I think the BLUE car will win.” If correct:  “I was RIGHT. The RED car won!” If incorrect:  “YOU were right. The BLUE car won.”

Facilitating Appropriate Lexical Stress When working with children on improving lexical stress, be sure you are working at the child’s optimum challenge point. Gradually increase the level of challenge to encourage success and facilitate generalization. The following sequence is recommended. 1. Identification of lexical stress 2. Production of single words with correct stress assignment a. imitatively b. spontaneously 3. Production of correct stress assignment in phrases and sentences a. imitatively b. spontaneously 4. Production of varied lexical stress patterns in conversational and connected speech activities

234   Here’s How to Treat Childhood Apraxia of Speech

To work on identifying lexical stress, begin with two-syllable words and determine if the child can identify which syllable has greater stress (which syllable was longer and/or louder). Initially, you may need to exaggerate the stressed syllable to demonstrate greater contrast between the stressed and weak syllable. As the child’s ability to identify stressed syllables improves, you will reduce the exaggeration of the syllable stress. Negative practice also can help children identify lexical stress. Have the child produce a word, first placing stress on one syllable and then on the other syllable (or listen to you produce a word with stress on opposing syllables) and see if the child recognizes which one sounds correct. Some children will continue to struggle with identification of syllable stress, even when they are beginning to produce syllable stress correctly, so there’s no need to wait for lexical stress identification to emerge before moving on to production. During production activities, begin by modeling correct lexical stress. The verbal models can be accompanied by a variety of other cues, for example, you can model the word while using hand gestures (e.g., mimicking stretching of dough). Blocks can be used to denote stressed and weak syllables with large blocks for stressed syllables/small blocks for weak syllables. If the child can read, you can use graphic cues, such as denoting the stressed syllable with larger letters than the weak syllables, placing a chip above the stressed syllable, or using a highlighter to bring the child’s attention to the stressed syllable. Examples of visual cues are illustrated in Figure 5–11.

Figure 5–11.  Examples of visual cueing for addressing lexical stress assignment.

5.  Establishing Vowel Accuracy and Natural Prosody   235

Visual biofeedback tools, like WASP and Voice Analyst, can be used to provide explicit instruction when working on lexical and sentential stress. In Figure 5–12, observe the difference in amplitude and pitch when the child produces the word contrast with stress on the second syllable (on the left) versus the first syllable (on the right). When choosing target utterances containing two or more syllables for treatment, begin by choosing words with trochaic stress patterns, in which a strong syllable is followed by a weak syllable (e.g., edit, bottom, separate, exercising). Words with iambic stress patterns, in which a weak syllable is followed by a stressed syllable or other nontrochaic stress patterns (e.g., surprise, believe, volunteer, community), can be targeted later in treatment. Careful selection of carrier phrases also influences the ease with which a child may be able to produce a target word in a phrase or sentence. When choosing carrier phrases, consider incorporating trochaic words into carrier phrases that follow a trochaic stress pattern and iambic words into phrases with iambic stress patterns (Bowen, 2009). Examples of trochaic and iambic words and carrier phrases are shown in Box 5–9. Lexical stress should always be addressed within the context of sentences, rather than stopping at the single-word level, to support flexibility and generalization of prosody within the context of connected speech. Worksheets can be found in the online materials along with practice word lists as exercises for developing more accurate lexical stress starting with syllable stress identification and moving through use of appropriate lexical stress within sentence contexts.

Facilitating Appropriate Intonation Within the context of speech production activities, you can incorporate work on using rising and falling intonation patterns. A variety of activities can be used to help children use appropriate and more varied intonation in their speech.

Figure 5–12.  Lexical stress variations in the word “contrast” using WASP for visual biofeedback.

236   Here’s How to Treat Childhood Apraxia of Speech

Box 5–9.  Examples of Trochaic and Iambic Words and Carrier Phrases Trochaic words and carrier phrases I can eat the (ap apple/car carrot/coo cookie/pea peanut but butter). Do you have the (pup puppy/but button/he helicop copter/te televi vision)? Put the (bas basket/can candle/pen penny) on the table. Iambic words and carrier phrases I bought a big (giraffe raffe/balloon loon/aqua quarium um). I know you won’t (agree gree/believe lieve/parti ticipate pate). He wants to play (croquet quet/today day/Mono nopoly).

Count Items Using Falling Intonation Counting is an activity that facilitates use of a falling intonation pattern at the end of the sequence. When counting objects with a child, an exaggerated intonation pattern should be modeled, with the final number accentuated and prolonged, and an obvious change in pitch. This type of exaggerated intonation during counting can be accompanied by hand gestures that match the intonations used (falling) to provide an accompanying visual cue.

Differentiate Sentence Types Using Falling and Rising Intonation Children with CAS may benefit from opportunities to practice using falling and rising intonation to differentiate between different types of sentences. The use of falling and rising hand gestures to accompany the intonation pattern provides a beneficial visual cue for some children. Blocks or paper squares used to denote each word of a sentence can be placed on a table, with the blocks raised or lowered at the end of the sentence, depending on whether the child needs to lower or raise pitch at the end of the sentence. Figure 5–13 illustrates how the use of falling and rising intonation can be practiced using identical sentences, alternating between producing the sentence as a declarative with falling inflection and as a question with rising inflection, as well as inflection changes between yes-no questions and declarative sentences. Children can be taught to identify yes-no questions words at the start of a sentence (e.g., is, are, can, does, do, will) that would trigger the use of rising intonation and then practice varying pitch to express rising and falling intonation in production practice. In Figure 5–14, the first two sentences from Figure 5–13 were recorded using WASP2, the first sentence with falling and the second sentence with rising intonation. The figure illustrates the sentence, “Bob ate 12 apples.” and “Bob ate 12 apples?”

Facilitating Use of Appropriate Prosodic Rhythm Just as the clinician would model appropriate syllable stress when introducing multisyllabic words in treatment, the clinician also would model appropriate rhythm of speech during sentence-level productions. Bringing a child’s attention and awareness to the rhythm of

Figure 5–13.  Example of using blocks for cueing rising and falling intonation patterns.

Figure 5–14.  Identical sentences with falling intonation and then rising intonation.

237

238   Here’s How to Treat Childhood Apraxia of Speech

language can be challenging because it is a natural pattern of stress and rhythm. Nevertheless, the use of modeling with accompanying visual cues, such as hand gestures that follow the rise and fall of stress in a sentence, can be useful. It also may be useful to contrast different ways of producing a sentence, such as contrasting a sentence produced with a robotic stress pattern versus a sentence produced with rhythmic application of stress. Children can practice saying the sentence “like a robot” and with a more natural rhythm so they can begin to hear and feel the difference in production of two distinctly different rhythmic patterns.

Facilitating Use of Chunking For children whose sentences and connected speech are more difficult to understand than their single-word production, it is important to work on chunking. Chunking of phrases into smaller clusters and practicing inserting pauses between these phrase chunks may make the motor plan for longer sentence production more manageable for children with motor planning difficulties. Chunking and pausing also may be useful in helping children gain a greater consideration for the needs of the listener and understand how things they do with their speech can help make it easier for the listener to understand them. One way to work on chunking is through reciting nursery rhymes. Nursery rhymes often utilize short phrases with pauses that are longer than those typically used in conversational speech. These nursery rhymes may facilitate the use of chunking and pausing: • Eeny, Meeny, Miny, Moe • Georgie Porgie • Hey Diddle Diddle • Hickory Dickory Dock • Humpty Dumpty • Little Bo Peep • One, Two, Buckle My Shoe • Pat-a-Cake, Pat-a-Cake, Baker’s Man • Rain, Rain, Go Away • Star Light, Star Bright Another way of introducing more natural sounding chunking and pausing in treatment is reciting the alphabet. There are natural pauses between letter chunks in alphabet recitation, and children can learn to tune into where these pauses occur and attempt to produce this well-rehearsed list with the insertion of pauses where they naturally would occur. Teach children to recognize where natural phrase breaks occur in language, first in shorter sentences that would have two phrasal units and one pause (e.g., “They are walking / to the store,”) and then in longer phrases with more than one pause (e.g., “They are walking / to the store / to buy some cookies.”) To accomplish this type of activity, children can read sentences and determine where a natural phrase break(s) would occur. In sentence-building activities, the child produces the first portion of the sentence, such as, “Mommy took me,” and gradually expands the sentence, “Mommy took me / to the park,” and then “Mommy took me / to the park / on Saturday morning.” Another activity could involve creation of silly sentences, in

5.  Establishing Vowel Accuracy and Natural Prosody   239

which the child chooses phrases from two or more piles that could be connected to form a longer sentence (e.g., The purple dinosaur / ate four cookies / at the rodeo). Children can practice using juncture by reciting lists. As a listener, it is easier to make sense of lists of items if the speaker produces the lists with a slight pause between the items on the list. Practice inserting pauses between words in well-rehearsed lists, such as counting from one to 10, listing the months of the year, or reciting the colors of the rainbow in the correct order. From there, children can begin to work on using pauses when producing novel lists, such as items on a birthday wish list, their favorite superheroes, or items on a shopping list.

Facilitating the Use of Varied Tones of Voice Varying tone of voice can begin quite early in treatment, but activities appropriate for older children can be introduced in treatment as well.

Introduce Exaggerated Tone of Voice Early in Treatment When working with very young children or older children with minimal expressive language, exclamations can be taught by modeling exaggerated tones of voice. Table 5–8 provides examples of words or phrases that may be introduced early in treatment to facilitate the use of exaggerated intonation patterns.

Recognize Different Tones of Voice Children can be taught to recognize that different vocal tones can be associated with different emotions and different speakers. Treatment activities may involve contrasting different vocal tones and asking the child to determine what emotion is being expressed (e.g., sad, happy, angry, tired). Pictures of faces that match various emotions may be beneficial during this Table 5–8.  Eliciting Varied Intonation Patterns Through Use of Exclamations Word/Phrase Exclamations

Contexts for Teaching Exclamations

“Whee!”

Sending cars, toy animals, or toy people down a slide

“Wow!”

Observing results from playdough machine

“Ready, set, go!”

Going on a swing, slide, or toy car

“Yikes!”

Toy vehicles crashing together

“Uh oh!”

Object falling to the ground

“Ka . . . boom!”

Block tower falling or being pushed over

“Mmm” or “Yuck”

Feeding food to dolls or puppets

“Oh, no!”

Toy animal or doll getting “hurt”

“Ta da!”

Completing a puzzle or other building toy

“Yahoo!”

Child accomplishing a challenging task

240   Here’s How to Treat Childhood Apraxia of Speech

activity. Helping children recognize differences in pitch and vocal quality also can be addressed using characters from books or television programs or from play characters (mommy, daddy, baby). Producing sentences using different character voices and asking a child to guess who was speaking (e.g., Cookie Monster versus Elmo) can help children recognize these differences in vocal tone and quality. Older children may be asked to distinguish between spoken sentences that sound sincere versus those that are spoken with a sarcastic tone of voice.

Produce Different Tones of Voice From very early on in treatment, children can be encouraged to practice using different tones of voice. They can pretend to “Say it like Cookie Monster” and then “Say it again like Elmo.” Children can help read along with familiar books that emphasize contrasts in vocal tone. An example would be The Three Bears. The child would be asked to say the lines the way the papa bear, the mama bear, and the baby bear would say them. Another activity would be to have the children choose an emotion card and produce a target utterance using a tone of voice that matches the emotion on their card. The same target utterances could be used, but the child practices manipulating various suprasegmental components such as pitch, loudness, vocal quality, and rate. For older children, using variations in vocal tone can be practiced while reading books or comic strips. Choose books that contain lots of dialogue and a wide variety of characters with different personality traits. Comic strips are an excellent choice because they are loaded with dialogue and typically incorporate characters with very transparent personality characteristics. Help the child understand and use variations in pitch, rate, and vocal quality to achieve distinctions in tone of voice. In summary, working on vowels and prosody is incredibly important and rewarding when supporting children with CAS. By working on these two areas in treatment, you are helping facilitate increased intelligibility, as well as helping the children’s speech sound more natural.

References Abbiati, C., & Velleman, S. (2021, July 8–10). Prosody!? Reducing the stress of assessment and intervention [Paper presentation]. Apraxia-Kids National Conference, Plano, TX, United States. American Speech-Language-Hearing Association. (2007). Childhood apraxia of speech [Technical report]. http://www.asha.org/policy Bowen, C. (2009). Children’s speech sound disorders. WileyBlackwell. Davis, B. L., Jacks, A., & Marquardt, T. P. (2005). Vowel patterns in developmental apraxia of speech: Three longitudinal case studies. Clinical Linguistics and Phonetics, 19, 249–274. https://doi.org/10.1080/026992 00410001695367 Davis, B. L., Jakielski, K. J., & Marquardt, T. M. (1998). Developmental apraxia of speech: Determiners of dif-

ferential diagnosis. Clinical Linguistics & Phonetics, 12, 25–45. https://doi.org/10.3109/02699209808985211 Dodd, B., Hua, Z., Crosbie, S., Holm, A., & Ozanne, A. (2006). Diagnostic Evaluation of Articulation and Phonology (DEAP). Pearson Assessment. Fudala, J. B., & Stegall, S. (2017). Arizona Articulation and Phonology Scale, Fourth Revision (Arizona-4). Western Psychological Services. Gerken, L., & McGregor, K. (1998). An overview of prosody and its role in normal and disordered child language. American Journal of Speech-Language Pathology, 7, 38–48. https://doi.org/10.1044/​1058-0360​.07​ 02.38 Gibbon, F. E. (2009). Vowel errors in children with speech disorders. In C. Bowen (Ed.), Children’s speech sound disorders (pp. 147–151). Wiley-Blackwell.

5.  Establishing Vowel Accuracy and Natural Prosody   241 Gibbon, F. E. (2013). Therapy for abnormal vowels in children with speech disorders. In M. J. Ball & F. E. Gibbon (Eds.), Handbook of vowels and vowel disorders (pp. 429–446). Psychology Press. Gibbon, F. E., & Mackenzie Beck, J. (2002). Therapy for abnormal vowels in children with phonological impairment. In M. Ball & F. Gibbon (Eds.), Vowel disorders (pp. 217–248). Butterworth-Heinemann. Hawthorne, K., & Fischer, S. (2020). Speech-language pathologists and prosody: Clinical practices and barriers. Journal of Communication Disorders, 87, 106024. https://doi.org/10.1016/j.jcomdis.2020.106024 Huckvale, M. (2021). Waveform, Annotations, Spectrogram & Pitch (WASP) (Version 2.1) [Mobile app]. https://www.speechandhearing.net/laboratory/wasp/ Ingram, S. B., Reed, V. A., & Powell, T. W. (2019). Vowel duration discrimination of children with childhood apraxia of speech: A preliminary study. American Journal of Speech-Language Pathology, 28, 857–874. https:// doi.org/10.1044/2019_AJSLP-MSC18-18-0113 Jakielski, K. J., & Gildersleeve-Neumann, C. E. (2018). Phonetic science for clinical practice. Plural Publishing. Kent, R. D. (1992). The biology of phonological development. In C. A. Ferguson, L. Menn, & C. Stoel-Gammon (Ed.), Phonological development: Models, research, implications (pp. 65–90). York Press. Kent, R. D., & Rountrey, C. (2020). What acoustic studies tell us about vowels in developing and disordered speech. American Journal of Speech-Language Pathology, 29, 1749–1778. https://doi.org/10.1044/2020_ AJSLP-19-00178 Lindamood, P. C., & Lindamood, P. D. (2011). The Lindamood Phoneme Sequencing Program for Reading, Spelling, and Speech (LiPS; 4th ed.). Pro-Ed. Maassen, B., Groenen, P., & Crul, T. (2003). Auditory and phonetic perception of vowels in children with apraxic speech disorders. Clinical Linguistics and Phonetics, 17, 447–467. https://doi.org/10.1080/02699​ 20031000070821 Munson, B., Bjorum, E. M., & Windsor, J. (2003). Acoustic and perceptual correlates of stress in nonwords produced by children with suspected developmental apraxia of speech and children with phonological disorder. Journal of Speech, Language, and Hearing Research, 46, 189–202. https://doi.org/10.1044/10924388(2003/015) Murray, E., McCabe, P., & Ballard, K. J. (2015). A  randomized controlled trial for children with apraxia of speech comparing Rapid Syllable Transition Treatment and the Nuffield Dyspraxia Pro-

gramme (3rd ed.). Journal of Speech, Language, and Hearing Research, 58, 669–686. https://doi.org/10​ .1044/2015_JSLHR-S-13-0179 Norris, J. (2003). Phonic Faces (2nd ed.). EleMentory. Peña-Brooks, A., & Hegde, M. N. (2007). Assessment and treatment of articulation and phonological disorders in children (2nd ed.). Pro-Ed. Pollock, K. E., & Hall, P. E. (1991). An analysis of the vowel misarticulations of five children with developmental apraxia of speech. Clinical Linguistics and Phonetics, 5, 207–224. https://doi.org/10.3109/02699​ 209108986112 Post, B., & Payne, E. (2018). Speech rhythm in development: What is the child acquiring? In N. EsteveGibert & P. Prieto (Eds.), Prosodic development in first language acquisition (pp. 125–144). John Benjamins. https://doi.org/10.1075/tilar.23.07pos Rosenbek, J., & Wertz, R. (1972). A review of fifty cases of developmental apraxia of speech. Language, Speech, and Hearing Services in Schools, 3, 23–33. ​​https://doi​ .org/10.1044/0161-1461.0301.23 Shriberg, L. D., Aram, D. M., & Kwiatkowski, J. (1997). Developmental apraxia of speech: II. Toward a diagnostic marker. Journal of Speech, Language, and Hearing Research, 40, 286–312. https://doi.org/10.1044/ jslhr.4002.286 Skinder, A., Strand, E. A., & Mignerey, M. (1999). Perceptual and acoustic analysis of lexical and sentential stress in children with developmental apraxia of speech. Journal of Medical Speech-Language Pathology, 7, 133–144. Strand, E. A. (2020). Dynamic temporal and tactile cueing: A treatment strategy for childhood apraxia of speech. American Journal of Speech-Language Pathology, 29, 30–48. https://doi.org/10.1044/2019_AJSLP19-0005 Strand, E. A., & McCauley, R. J. (2019). Dynamic Evaluation of Motor Speech Skill (DEMSS). Paul H. Brookes. Strand, E. A., & Skinder, A. (1999). Treatment of developmental apraxia of speech: Integral stimulation methods. In A. Caruso & E. Strand (Eds.), Clinical management of motor speech disorders in children (pp. 109–148). Thieme. Velleman, S. L. (2003). Childhood apraxia of speech resource guide. Delmar Learning. Williams, P., & Stephens, H. (2010). The Nuffield Centre Dyspraxia Programme. In L. Williams, S. McLeod, & R. McCauley (Eds.), Interventions for speech sound disorders in children (pp. 159–177). Brookes.

CHAPTER

6

Facilitating Speech and Language in Minimally Verbal Children

T

he suggestions provided in earlier chapters describe methods to shape increasingly accurate and flexible speech production in children with childhood apraxia of speech (CAS). For children to increase the complexity of word shapes and precision of articulation, however, they need to have some volitional control over the movement and timing of the speech mechanism. They need to be able to imitate with some degree of reliability. What about very young children who are at risk for sensorimotor speech and language impairment (e.g., children with a known etiology associated with sensorimotor speech impairment) and children who are not yet reliably able to coordinate the movement and timing of respiration, phonation, resonance, and articulation? This chapter focuses on ways to facilitate speech and language development in infants and toddlers at risk for speech and language delays, to motivate young children and children who are reluctant to attempt speech, and to facilitate vocal and verbal development in young children with suspected CAS or older children with very severe CAS who do not yet readily imitate. It also addresses development of early expressive language skills in children with CAS and the use of augmentative and alternative modes of communication (AAC). Some of the strategies described in this chapter are beneficial in treatment of nonverbal or minimally verbal children despite their etiology. It is important to keep in mind, however, that a child’s absence of verbal language and lack of verbal imitation skills can be attributed to etiologies unrelated to sensorimotor speech planning deficits. For example, a child with a severe cognitive impairment may not have some of the underlying cognitive/linguistic capacities required to develop verbal communication skills. A child with autism spectrum disorder may have weak communicative intent that will lead to delayed use of expressive language. A thorough discussion of differential diagnosis can be found in Chapter 2.

243

244   Here’s How to Treat Childhood Apraxia of Speech

Infant Vocal Development The vocal development of very young children is an evolving process. Although there is a general sequence from very early reflexive and vegetative sounds beginning at birth to production of jargon by the middle of the second year of life, there is overlap among the stages in the vocal development process. Nathani et al. (2012) describe the stages of vocal development in children from birth to 18 months. Box 6–1 summarizes these stages. Note how there is overlap between the stages. For example, a child will continue producing quasi-resonant nuclei even as they enter the stage where they begin to produce some fully resonant vowel-like sounds. When working with children who are not yet producing true words, you can chart their stage of vocal development and begin to build upon what they do have to move them closer to true canonical babbling, which is a precursor to use of true words.

Programs for Establishing Early Sensorimotor Speech Development and Expressive Language Skills in Infants and Toddlers at Risk for Sensorimotor Speech Disorders A number of programs have been used to facilitate speech and language in very young children with delayed speech and language development or who are at risk for communication challenges. Three of these programs are described here.

Babble Boot Camp An exciting new area of research pertaining to early intervention is showing us how children at risk for speech and language disorders can benefit from a proactive therapy approach starting with infants as young as 2 months old. The therapy program is called Babble Boot Box 6–1.  Summary of Vocal Development From Birth to 18 Months 0–2 months:  Child produces reflexive sounds; vegetative sounds (burps, sneezes); crying and fussing; quasi-resonant nuclei (e.g., grunt-like sounds that lack full resonance) 1–4 months:  Child produces clicks and raspberry noises; laughter; CV-like syllables without true vowels; vowel-like sounds that are fully resonant but not able to be transcribed 3–8 months:  Child produces fully resonant vowels and sequences of vowels; squeals; marginal babbling 5–10 months:  Child produces true CV syllables; repeated CV syllables 9–18 months:  Child produces complex syllables beyond CV syllables (e.g., VC, CCV, CCVC); two-syllable sequences (e.g., VCV, VCVC); diphthongs; jargon (i.e., series of syllables with varied prosodic patterns) Based on Nathani, Ertmer, & Stark (2006).

6.  Facilitating Speech and Language in Minimally Verbal Children   245

Camp (BBC). BBC is implemented through parent training by a speech-language pathologist (SLP) who specializes in early child development. Beate Peter, PhD, and her research team from Arizona State University, Washington State University, University of Washington, University of Minnesota, and Saint Louis University have been studying the effect of BBC on children with classic galactosemia (CG) ages 8 to 24 months. CG is a genetic disorder where the child is unable to metabolize galactose and often results in sensorimotor speech disorders and language impairment. Babies are universally screened for CG; thus, parents know immediately if their child has it. The high incidence of speech and language disorders and the early diagnosis make this the ideal population to study the impact of proactive intervention in the first 2 years of life. Preliminary results are very promising (Peter et al., 2019, 2021). Previous research indicates that 24% to 63% of children with CG have CAS, and 50% to 78% have a developmental language disorder (Peter et al., 2021). However, results from their 2021 study showed that after participation in BBC, all 12 children in the study receiving treatment had typical language scores, and 11 of the 12 had typical articulation scores. In the control group, one of the three untreated children had low articulation and expressive language scores. Hence, the evidence strongly supports this proactive method. With the increase in genetic testing and knowledge of which genes lead to disruption in neural development, the likelihood of other populations benefiting from this approach is high. It is also important to point out that BBC is taking place via telepractice. Given the increase in telepractice since COVID-19, this turned out to be fortuitous (for detailed instructions on BBC, go to https://osf.io/sy3en/). Following is a brief summary of the program. Parents are first educated on typical communication milestones, as well as red flags for delays. Parents are then introduced to a progression of activities and routines that support typical development, and are coached in strategies to elicit specific communicative behaviors. Table 6–1 provides a summary of the activities and routines associated with BBC. An expected age of achievement for each activity/routine is provided; however, each child progresses through the program at their own rate, regardless of their chronological age. Parents are provided with a pamphlet that explains each activity and how often to engage in the activity. The activities are to occur at least 5 minutes a day (5+) or as part of the daily routine. Although many of these activities may seem like they would naturally occur between a caregiver and their child, parent-child interactions tend to wain when a baby lacks vocalizations and babbling, as there is little initiation from the baby or reinforcement to the parent when the baby does not babble in response to the parent’s vocalizations. Activities 7 and 8 could be extremely beneficial in assisting the parent during this important stage of development. Babbling is crucial to the child’s speech development, as this is when “the infant is learning the mapping between acoustic-phonetic targets and the movement of their articulators to achieve those targets” (Rvachew & Brosseau-Lapré, 2021, p. 207). Using videos of babies babbling is consistent with research on the benefits of video modeling (Beating & Maas, 2021). Research from Franklin et al. (2014) further supports the benefits of parental interaction on the development of infant vocalizations and volubility and suggested that their TD participants learned that their vocalization had social value for parental interactions by 6 months of age. There are potential effects on the child’s skill development when treatment is provided proactively in children at risk for significant communication disorders. Early eye contact and talking to the baby set the stage for coupling of visual and auditory signals, while expressing emotion through our tone of voice and facial expression helps the child develop increased

Table 6–1.  Progression of Activities and Routines for Infants and Toddlers Based on Babble Boot Camp Research Expected Age of Acquisition in Typically Developing Children

Progression of Activities and Routines

Birth to 24 months

1. Make regular eye contact with the baby to establish and maintain bonding.

Birth to 4 months

2. Talk to the baby and imitate the child’s nonreflexive sounds to establish turn taking.

Birth to 8 months

3. Use facial expressions to show emotions to establish and maintain bonding.

2–8 months

4. Reinforce vocalizations by activating a light-up toy in response to volitional sound production.

2–8 months

5. Imitate or respond to the child’s cooing to reinforce vocalizations.

4–8 months

6. Reinforce dyadic exchanges by making silly faces and playing Peek-a-Boo.

6–12 months

7. Model babbling and gently move the child’s lips while the child is vocalizing to stimulate babbling.

6–10 months

8. Increase quantity and quality of babbling by visiting with other babies or showing the child videos of other babies babbling.

6–12 months

9. Model and shape greetings (such as waving, saying “Hi”) to increase social interaction skills.

6–12 months

10. Facilitate increased receptive vocabulary by pairing verbal cues with nonverbal cues.

6–24 months

11. Read books together to support increased receptive and expressive vocabulary.

8–18 months

12. Create a photo book to show the child pictures of important people, places, and objects in the family to increase receptive and expressive vocabulary.

8–24 months

13. Sing songs and pair the speech rhythm with the music rhythm to build rhythmic, phonemic, and rhyme awareness.

8–24 months

14. Label the people and objects to which the baby points to build receptive and expressive vocabulary.

10–24 months

15. Make comments about things that are happening using simple sentences to build language comprehension.

12–18 months

16. Use expansion by producing simple phrases/sentences in response to the child’s single-word utterances to build expressive syntax.

14–24 months

17. Expand the child’s short utterances by repeating them in longer sentences to build expressive syntax.

Note.  Adapted from B. Peter (2020). Babble Boot Camp Activities and Routines.

246

6.  Facilitating Speech and Language in Minimally Verbal Children   247

awareness of pragmatic communication. When the parent responds to the child’s vocalizations and models and responds to babbling, the child begins to associate the auditory and motor behaviors for vocalizations and speech-like sounds and increase their phonetic inventory. Further improvements in phonemic inventory and articulation skills are enhanced when the parent labels objects in the environment and models words. The use of expansion will support an increase in the complexity of the syntax of the child’s language. Given the success of BBC for children with CG, the research has expanded to children with Down syndrome and children who were born prematurely.

Wee Words There are other programs that support children ages 2 years and above with suspected speech and language disorders. One such structured treatment program for children of at least 2 years of age is the Wee Words program. The Wee Words program (Kiesewalter et al., 2017) was designed for children ages 2:0 to 3:6 with suspected speech sensorimotor planning difficulties. Wee Words is a parent-child group-based program that focuses on facilitating development of children’s imitation skills, speech sound repertoires, intelligibility, and expressive vocabulary development. Wee Words combines principles of motor learning using a variety of multisensory strategies to facilitate imitation skills, increase complexity of syllable shapes, increase phoneme repertoire, and increase expressive language skills. During an initial parent training session, parents are provided with information about typical speech sound development, principles of motor learning, and strategies to elicit communication and imitation skills (e.g., cueing, imitating the child, encouraging the child to watch their face while modeling, providing specific feedback). Treatment occurred in groups, with five parent-child dyads, along with an SLP and a communicative disorders assistant who led group activities (e.g., songs, book reading). In addition, they provided coaching for each individual parent-child dyad. Each parent-child dyad would be provided with a specific set of toys and suggestions for how to facilitate production of target utterances, target phonemes, and selected syllable shapes during the activities. In a clinical report of pre- and posttreatment measures, Kiesewalter and colleagues reported that the children who received treatment showed improvement in expressive vocabulary, imitation skills, and increased their consonant phoneme repertoire and variety of word shapes.

Let’s Start Talking The Let’s Start Talking (LST) program (Hodge & Gaines, 2017) provides support for preschool-age children of approximately 3.0 to 3.5 years of age with normal receptive language and severely delayed expressive speech and language by “helping children to learn to produce intelligible one- and two-syllable words with simple word shapes, using their existing phonetic inventory, in addition to systematically building their inventory (including vowels)” (p. 37). LST follows and builds upon Dynamic Temporal and Tactile Cueing (DTTC) and the PROMPT Motor Speech Hierarchy (see Chapter 4). Ten parent-child dyads received 8 weeks of twice-weekly individual treatment. Following treatment, significant increases were observed in several areas of speech development, including number of consonant types produced, syllable shape and consonant accuracy, use of recognizable speech sounds, number of intelligible words, and number of intelligible word types.

248   Here’s How to Treat Childhood Apraxia of Speech

Facilitating Vocal and Verbal Development in Minimally Verbal Children When children are able to imitate at least some speech sounds, their productions can be shaped into intelligible words. For children who do not imitate speech reliably, however, other treatment strategies must be utilized. DeThorne et al. (2009) described six evidence-based treatment strategies for facilitating speech development in young children who are not yet readily imitating speech sounds. The six strategies are as follows: • Minimize the pressure on the child to speak because pressure to speak may increase frustration and anxiety related to communication. • Imitate the child’s actions and sounds to facilitate the child’s own imitation skills. • Utilize exaggerated intonation and slowed tempo when speaking to the child so the child develops a greater awareness of the salient aspects of the sounds and words you are attempting to elicit. • Provide salient auditory, visual, tactile, and proprioceptive feedback so the child’s ability to process information related to articulatory movement is maximized. • Provide access to AAC, even while working on sensorimotor speech planning, to support the child’s social and linguistic skill development. • Avoid emphasis on nonspeech oral motor exercises (NSOMEs), as these have not been shown in peer-reviewed research to facilitate speech production. These and other strategies are described in the following section in further detail.

Minimizing Pressure on the Child to Speak When a child is reluctant to attempt verbal imitation, DeThorne et al. (2009) recommend reducing use of commands to speak or requiring the child to say a word before receiving a desired outcome (e.g., If you want the ball, tell me “ball.”). Instead, they suggest using these tactics: • Follow the child’s lead during play, commenting on what the child is interested in. • Use puppets as interactive partners. The child can interact vocally, verbally, and gesturally with the puppet, observe the clinician interacting with the puppet, and direct the puppet to do and say things (e.g., when playing doctor, direct the puppet to say, “ah”). • Incorporate familiar routines and interactions in naturalistic settings (e.g., giving baby a bath, feeding baby, and putting baby to bed). • Avoid “test questions” that put the child on the spot (e.g., Tell us who you saw at the playground today. What did you eat for lunch?) and requests for direct imitation (e.g., “Say hi”). • Reduce time pressure to communicate. Certainly, the child can be encouraged to communicate verbally, just not pressured to do so. When the child does vocalize, the clinician can assign meaning to the child’s vocalization. If the child says “baba” while babbling, the clinician can bring out the bubbles, saying, “I’ve

6.  Facilitating Speech and Language in Minimally Verbal Children   249

got bubbles right here. Bubbles!” If the child is pointing to a ball and says “da,” the clinician can recognize “da” as a communicative request, give the child the ball, and tell the child how much you love their sounds and words (e.g., “Oh, you want the ball. I love when you use your words to tell me what you want!”). When the child makes babbling sounds, encourage the caregivers to express joy and excitement about how much they love the child’s sounds and guide them in ways to make those sounds meaningful. Build anticipatory vocal and verbal routines into play with the child. Games like peekaboo or verbal routines like “ready, set, go” provide the child with anticipation of what word is going to come next. If the child is engaged in a game of peekaboo and wants to keep going, you can pause right before saying “boo” and see if the child responds. Sometimes children will not speak the word but may close and round their lips as if they are getting ready to say the word. Reinforce the child’s movement gestures by saying, “Your mouth was ready to say ‘boo!’ Great job moving your lips!” Building anticipatory routines is gradual and can take time for children with severe sensorimotor planning challenges. Box 6–2 provides an example of a routine that encourages both gestural and vocal responses. Box 6–2.  Building and Shaping Anticipatory Responses The child and adult are playing on the floor. The child is feeding a baby doll and pretending to drink from a cup. The child offers a cup to the adult. Adult:  (Making drinking noises while pretending to drink from the cup with one hand and pointing to the approximate place of constriction for /g/ near the throat with the other) “guh guh guh guh guh guh guh, ah” Child: (Giggles) Adult:  (Pretends to drink from the cup again) “guh guh guh guh guh guh guh, ah” Child: (Giggles) Adult:  (Pretends to drink from the cup again) “guh guh guh guh guh guh guh, ah” Child:  (Giggles even more loudly) Adult:  (Holds the cup up, but does not pretend to drink; pauses and waits for a response from the child) Child:  (Pushes the cup toward the adult’s mouth and smiles up at the adult expectantly) Adult:  (Pretends to drink from the cup) “guh guh guh guh guh guh guh, ah” Child:  (Giggles loudly) Adult:  (Sets the cup down) Child:  (Picks up the cup and hands it to the adult, then moves the cup toward the adult’s mouth) Adult:  (Tips the cup, as if drinking, but does not make the associated drinking noises) Child:  (Says [dʌ] while looking up at the adult) Adult:  (Continues to “drink” from the cup) “guh guh guh guh guh guh guh, ah” Child:  (Smiles and giggles)

250   Here’s How to Treat Childhood Apraxia of Speech

Imitate the Child’s Movements and Sounds For children who have not yet begun to imitate reliably, the clinicians and caregivers can begin imitating what the child is doing. When the child makes raspberry sounds or bangs their hands on the highchair tray, the adult can do what the child does in a joyful and animated way. If the child enjoys the adult reaction, they will want to keep this activity going by repeating the same action, or the child may do something new and see what type of reaction the child receives. This turn-taking routine, when solidly established, can be shifted from child-led to adult-led, so the child and adult are mirroring one another. DeThorne et al. (2009) described research by Snow (1989) that showed positive associations when adults increased their imitation of the child and an increase in the child’s use of imitation. When a child begins to vocalize and verbalize, it is beneficial to talk with the child about what the child is doing and how the child is doing it. If the child is producing /ba.ba.ba/, tell the child that their lips are opening and closing. The child who is making raspberry sounds can be told that their lips are vibrating or that the child sounds like a motorboat. These descriptions may lay a foundation for the child to understand their movements and can be used as reminders later for how to produce specific target sounds and words.

Model Using Exaggerated Intonations and Slowed Tempo DeThorne et al. (2009) recommend using more exaggerated intonation patterns and speaking at a slower rate of speech when providing models for minimally verbal children. They suggest the “primary rationale for this strategy is that neural mechanisms involved in singing can be used to ‘bootstrap’ speech production due to partially distinct but also overlapping neural networks” (DeThorne et al., 2009, p. 138). The enhanced melodic nature of speech when we model with an exaggerated intonation pattern is similar to singing or chanting. Introducing melody and slower speaking rates enhances the speech model for the child. Exaggerated prosody can be combined with Focused Stimulation (Ellis Weismer & Robertson, 2006). Focused stimulation is used to heighten the child’s awareness of specific phonemes or phoneme combinations. Target utterances can be emphasized by using these strategies: • Pausing just before the target word is produced (e.g., “Look, I found a . . . ball. Oh, here’s another . . . ball.”). • Producing target words more slowly and more frequently (e.g., “Duck’s going uuuup the ladder. Here he goes — uuuup, uuuup, uuuup. Duck’s going uuuup.”). • Securing the child’s visual attention toward your mouth by pointing to your mouth, using gestural cues, or holding desired items near your mouth while you produce the target words. • Using greater vocal intonation when modeling the target word. You can make your voice slightly louder and incorporate more dramatic vocal intonation and prosody when producing the target word. By combining pausing, slower productions, visual attention, and vocal inflection when modeling target words, these keywords become more salient for the child, increasing the likelihood that the child will attempt to imitate them. Singing provides a natural way of incorporating exaggerated prosodic patterns, vowel prolongation, and repeated modeling of target utterances. In addition to singing familiar

6.  Facilitating Speech and Language in Minimally Verbal Children   251

children’s songs, you can sing while modeling target utterances and create personal tunes that incorporate the child’s target utterances. For example, for a child working on the phrase, “Let me do it” or the word “do,” the clinician could sing “Let me do it” to the melody of Frere Jacques repeating the target multiple times, pausing where appropriate to allow the child to fill in some of the words: Let me do it, let me do it. Let me do it! Let me do it! Let me let me do it. Let me let me do it. Let me do it! Let me do it! Chanting provides a fun way of using a call-out and response-style melody during therapy. Chants can incorporate functional words and phrases that are child specific: Clinician:  My name is Aaron. My name is . . . Child: Aaron Clinician:  Yeah my name is Aaron. My name is . . . Child: Aaron Clinician:  People call me Aaron. People call me . . . Child: Aaron Clinician:  Yeah people call me Aaron. People call me . . . Child: Aaron Table 6–2 provides a list of several songs for young children that are useful for facilitating sound effects, simple word production, vowel variety, vocal imitation, and nonvocal imitation.

Provide Salient Auditory, Visual, Tactile, and Proprioceptive Feedback Children with CAS may have reduced somatosensory awareness and respond less favorably to sensory feedback in natural circumstances. Thus, providing more salient sensory feedback is recommended. DeThorne et al. (2009) recommend using amplification (e.g., speaking through an Echo-microphone — available at some toy stores, party stores, or online; a Toobaloo — small U-shaped toy that can be held up to the ear and mouth; paper towel or wrapping paper rolls; or a piece of PVC pipe) to provide altered and enhanced auditory feedback. Cueing can be enhanced using mirrors and puppets with movable mouths or placing a wide tube around the clinician’s mouth so the child can focus on the clinician’s mouth movements with reduced distractions. Many children with apraxia demonstrate reduced tactile and proprioceptive processing (Ayres, 2005). By adding tactile and proprioceptive cues, we increase the child’s ability to process information related to the motion, direction, force, and timing of the articulators. For example, when modeling the word moo, the clinician could press their fingers against the child’s lips and hold for a second for /m/ before transitioning to the vowel. Shaping the child’s lips in a rounded formation for the /u/ vowel in moo also offers increased tactile/proprioceptive saliency for the child. These cues provide a child with a sense of what it should feel like to say the target words, thus helping the child associate the feeling of the movement gesture with the sound of the utterance.

252   Here’s How to Treat Childhood Apraxia of Speech

Table 6–2.  Popular Children’s Songs and Chants to Promote Early Speech Skills in Children Song Titles

Speech and Language Skills Facilitated

Apples and Bananas

Vowel variety

Baby Bumblebee

Animal sounds; simple word production

BINGO

Vowel /o/

Down by the Bay

Rhyming; simple word production; vowel variety

Eentsy Weentsy Spider

Simple word production through sentence completion

Five Little Ducks

Counting; simple word production through sentence completion

Five Little Monkeys Jumping on the Bed

Counting; simple word production through sentence completion

Head, Shoulders, Knees, and Toes

Simple word production; vowel variety

I Love You (The Barney Song)

Simple word production

I Caught a Fish Alive

Counting; simple word production through sentence completion

If You’re Happy and You Know It

Vocal and nonvocal imitation

John Jacob Jingleheimer Schmidt

Complex word production

London Bridge Is Falling Down

Simple word production through sentence completion

Old Macdonald Had a Farm

Animal sounds and vowel variety

One, Two, Buckle My Shoe

Simple word production; counting

Pat-a-Cake

Simple word production (especially bilabials)

Pop Goes the Weasel

Simple word production; nonvocal imitation

Ring Around the Rosy

Simple word production

Row, Row, Row Your Boat

Simple word production; early developing vowels /i, o/

The Alphabet Song

Vowel variety; production of CV and VC combinations

The Wheels on the Bus

Simple word production

This Is the Way . . .

Vocal and nonvocal imitation; simple word production

This Old Man

Simple word production

Twinkle, Twinkle Little Star

Simple word production

Wibbely Wobbely Woo

Complex word production

6.  Facilitating Speech and Language in Minimally Verbal Children   253

Embed AAC Into Treatment According to ASHA (n.d.), “Augmentative and alternative communication (AAC) describes multiple ways to communicate that can supplement or compensate (either temporarily or permanently) for the impairment and disability patterns of individuals with severe expressive communication disorders.” AAC does not imply a specific mode of communication but, rather, a wide array of communication methods that can be used in combination. Communication modes typically are divided into two types: aided and unaided communication. Unaided communication is any type of communication that relies only on the person’s body to convey the message (e.g., speech, gestures), whereas aided communication requires the use of an external tool to convey the message. The range of aided communication options is broad and may include low-tech options such as writing or picture boards, as well as high-tech options such as voice output communication aids (VOCAs). Figure 6–1 provides a diagram of various communication systems sorted between aided and unaided modes. These modes of communication can be used in combination; therefore, it is highly unusual for an individual to rely solely on one mode to meet all communication needs. In fact, multimodal communication should be encouraged.

Benefits of AAC AAC can be particularly beneficial for children with severe sensorimotor speech disorders who have limited expressive speech or reduced speech intelligibility. A child with very limited speech may rely on AAC as the primary means of communication. For a child who produces speech, but whose speech intelligibility is limited, AAC can be a way to augment existing speech. Whether AAC is used regularly or intermittently, temporarily, or long term, children with CAS may receive several benefits from its use: • increased efficiency of communication • increased effectiveness of communication • increased quantity and quality of the child’s language • increased opportunities for social interaction across a wider range of settings, with a wider variety of individuals, and for a wider range of communicative functions • decreased reliance on familiar adults to serve as interpreters • decreased communicative passivity • reduced challenging behaviors caused by limited ability to express ideas

Considerations in Use of AAC in Treatment A number of dilemmas face SLPs with regard to the use of augmentative communication as part of treatment programs for children with apraxia of speech. Questions may surface concerning when the right time would be to introduce AAC into treatment, how much time to spend teaching the child to use the augmentative system when a significant amount of time is needed to address speech itself, which augmentative system is most appropriate for a given child at a given age, what vocabulary to select for a communication device, and how to

254   Here’s How to Treat Childhood Apraxia of Speech

Figure 6–1.  Modes of communication.

introduce the topic of AAC with parents. When AAC looks like it may be used as more than a temporary incorporation of some manual signs or use of a limited selection of pictures to use when verbal communication is breaking down, it will be important to complete a multidisciplinary AAC evaluation where a team of professionals assesses cognitive function, motor

6.  Facilitating Speech and Language in Minimally Verbal Children   255

accessibility, visual acuity and hearing status, and speech and language skills. This will help guide the team toward selecting the most appropriate AAC system for the child. Kuhlmeier (2021) recommends applications like AAC Genie (https://humpsoftware.com/aacgenie.html), the Communication Matrix (https://www.communicationmatrix.org/), and the Student, Environment, Task, and Tools (SETT) framework (Zabala, 2005) as frameworks for selection of AAC systems.

When Should AAC Be Introduced Into Treatment? Basic manual signs and communication boards can be introduced right from the start of treatment, even for very young children with CAS. There is no need to wait for extended periods of time before introducing signs, gestures, or picture selection strategies into treatment. If AAC is provided only as a last resort and only after all attempts to elicit speech have been tried, the child will have missed months or years of opportunities to establish intentional, symbolic communication, and to become an active participant in the communication process. The child can be taught manual signs and natural gestures for high-frequency words (more, mine, all done, yes, no) while simultaneously working on verbal production of these same words. Picture boards and books can be provided, and the child can be taught to use these pictures to make choices or comments during various routines (play, mealtime, bath). After adequate verbal production has been attained for the target word, the use of signs or picture selection strategies will be extinguished naturally.

How Much Time Should Be Devoted to Use of AAC? Intensive work to address the child’s speech production should be at the forefront of the treatment program for a child with CAS. To support the child’s expressive language and social communication, however, a multimodal program of communication should be integrated into the child’s treatment. Cumley and Jones (1992) recommend facilitating the use of gestures, manual signs, and picture symbols as adjuncts to speech therapy in young children with CAS. Finding the right balance of intensive practice in speech praxis and continuing to enhance expressive language using an augmentative system of communication is challenging, but necessary, for some children with CAS. When AAC is introduced, parents should be taught how to incorporate it into the child’s daily routines. If children have opportunities to practice communicative interaction using AAC in a wider range of settings, it allows the SLP to spend a greater portion of time addressing prevocal and vocal communication goals during the treatment sessions.

What Type(s) of AAC Systems Are Most Beneficial for Children With CAS? The types of communication modes that would be most beneficial would depend on the individual needs and abilities of each child. To determine which type(s) of AAC to introduce to a child, consider the following factors: • Portability.  How easy is it for the child to transport the system? • Readability.  Can the communicative partners easily interpret the child’s message? • Cost.  What is the cost of the system, including programming and repairs?

256   Here’s How to Treat Childhood Apraxia of Speech

• Flexibility and efficiency.  How much flexibility does the system offer to formulate any possible message, and how quickly and efficiently can the child formulate a message? • Motor requirements.  Does the child have the sensorimotor skills and coordination necessary to use the system effectively?

Selecting Vocabulary for Communication Boards When selecting vocabulary for communication boards (picture boards, low- and high-tech systems), be sure to choose appropriate vocabulary. Consider the following: • Choose vocabulary that will facilitate a wide range of communicative functions (e.g., greeting, requesting, rejecting, protesting, describing, commenting, providing information, expressing feelings, joking). • Vocabulary should be appropriate for the child’s age and cognitive functioning. • Incorporate vocabulary that is specific to the child’s environments and interests (home, school, community). • Select vocabulary that represents a wide range of linguistic categories to allow for opportunities to combine words into phrases and sentences (e.g., names, nouns, verbs, descriptors, interjections, conjunctions). • Vocabulary should provide opportunities for the child to participate more fully in imaginative play. • Select vocabulary that helps facilitate greater participation in the classroom and other group activities (circle-time, curriculum units, games). • Change vocabulary as needed to facilitate linguistic growth. Cumley and Jones (1992) recommend the use of miniboards for children who are mobile to reduce the challenges of portability. Miniboards, described by Beukelman and Mirenda (1992), are single topic boards that are placed in specific locations (e.g., bathtub area, kitchen table, the child’s play area, reading corner in the classroom), so they are available readily without having to be transported from place to place. Miniboards can be created to facilitate communication related to specific books the child is reading, specific thematic units in school, and special activities or events (holidays, birthday parties, field trips). Portability also can be achieved by using communication wallets that can be placed in a pocket or picture rings that can be attached to a belt or backpack. These may be handy to use in the community (e.g., ordering food at a restaurant) or for quick access to frequently used phrases across multiple environments.

Addressing Parent Concerns About AAC Parents often express serious concerns regarding the introduction of augmentative communication into treatment. Understandably, they worry about whether their child may lose the desire or motivation to work on verbal communication if the child is provided with an easier way to express ideas. Take time to educate parents about the complex nature of communication and how all areas of communication — receptive and express language, social language, and articulation — need to grow together in unison. If speech is very slow in coming and the child has no other ways to reliably communicate, the child’s expressive language development and social language functioning will be compromised. It can be helpful to share with

6.  Facilitating Speech and Language in Minimally Verbal Children   257

parents that speech development is facilitated when AAC is incorporated into communication programs (Millar et al., 2006; Zangari & Kangas, 1997).

Avoid Emphasis on NSOMEs There has been a great deal of controversy regarding the use of NSOMEs in speech therapy. No study has been published to date in peer-reviewed journals showing NSOMEs facilitating any significant changes in speech production of a child with CAS. That said, it may be appropriate to work on some functional, nonspeech skills — such as blowing, kissing, licking lips, and so forth — that may have social implications for a child with oral apraxia. It may also be appropriate to shape the movement required for accurate production of a specific phoneme using a nonspeech activity. A child struggling to achieve lip rounding for /u/ and /o/ may benefit from rounding lips around a lollipop or straw to achieve lip rounding while being asked to vocalize the vowel. Tongue clicks may help shape production of alveolar phonemes, and coughing may be beneficial for shaping velar phonemes. A note of caution here is that intensive, repetitive production of NSOMEs to build muscle strength is not appropriate for treating children with CAS, as children with CAS need to work on volitional speech productions to build muscle memory, not on strength building.

Facilitate More Robust Imitation Treatment of CAS requires the child to watch the clinician and try to imitate what the clinician says. Young and minimally verbal children may struggle with imitation, so imitation will need to be taught. Begin by determining what types of movements (gross motor, fine motor, oral-facial, vocalizations, speech) the child is able to imitate, and progress from there. The following is a general guide to facilitating motor imitation skills in children who do not readily imitate speech. Although this list is a progression from simple to more challenging motor movements, these stages overlap, so it should be considered a rough guide: • large motor movements (e.g., clapping hands, banging on a table, stomping feet) • actions with objects (e.g., banging a stick on a table like a drum, banging two blocks together) • more subtle movements, gestures, and signs (e.g., wiggling fingers, shaking head, producing simple manual signs such as more, eat, or cookie) • oral-facial movements (e.g., clicking and protruding tongue, licking lips, blowing kisses, smacking lips) • vocal play (e.g., raspberries, gurgling) • vocal imitation (e.g., “baba,” “puhpuhpuh,” “mmmm,” “uh oh”) Encourage the child to make silly noises and produce environmental sounds. Sounds such as animal and vehicle noises often develop prior to the production of true words. Examples of toys that may elicit these early sounds include the following: • toy animals (growling bear, panting, or barking dog, meowing cat, braying horse, snorting pig, chattering monkey, buzzing bee) • toy vehicles (beeping truck horn, helicopter propeller, zooming motorcycle, screeching car brakes, steam engine noise, train horn noise)

258   Here’s How to Treat Childhood Apraxia of Speech

• food-related toys (popcorn popping, fry pan sizzling, water faucet noise, gulping drinks, “ah” after a thirst-quenching drink, noisy chewing, yummy “mmmmm” food, microwave beeping) • dolls and other people toys (hiccups, coughing, sneezing, burping, startle “ah,” noisy yawn) Many books for young children encourage the production of sound effects. The books in Box  6–3 offer opportunities to facilitate sound effects such as animal noises and environmental sounds. Box 6–3.  Books to Elicit Environmental Sounds Battaglia, A. (1984). Animal sounds. Goldencraft Publishing. Bluemle, E. (2017). Tap tap boom boom. Candlewick Press. Boynton, S. (1995). Doggies. Simon & Schuster. Boynton, S. (1995). Moo, baa, la la la. Simon & Schuster. Brown, C. M. (1992). City sounds. Greenwillow Books. Brown, M. W. (1942). The indoor noisy book. Harper & Row. Brown, M. W. (1947). The winter noisy book. HarperCollins. Brown, M. W. (1951). The summer noisy book. HarperCollins. Brown, M. W. (2002). Bunny’s noisy book. Hyperion Books. Butler, J. (2003). If you see a kitten. Peachtree Publishing. Butler, J. (2007). Can you growl like a bear? Peachtree Publishing. Calmenson, S. (1991). Zip, whiz, zoom! Joy Street Books. Carle, E. (1969). Have you seen my cat? Scholastic. Carle, E. (2000). Does a kangaroo have a mother, too? Scholastic. Cowell, C. (2000). What shall we do with boo-hoo baby? Scholastic. Crow, N. (2017). Can you say it, too? Brrr! Brrr! Candlewick Press. (There are many books in the Can you say it, too? series). Martin, B. (1991). Polar bear, polar bear, what do you hear? Henry Holt & Company. Massie, D. R. (1963). The baby beebee bird. HarperCollins. Mayer, M. (1977). Ah-choo. Pied Piper Books. Most, B. (1994). The cow that went oink. Scholastic. Nygaard, E. (1998). Snake alley band. Doubleday. Patricelli, L. (2003). Quiet loud. Candlewick Press. Russo, M. Bunnies are not in their beds. Dragonfly Books. Santoro, C. (1993). Open the barn door. Random House. Seuss, Dr. (1970). Mr. Brown can moo! Can you? Random House. Sirett, D. (2005). Baby talk. DK Publishing. Stanley, M. (2003). What do you say? Little Simon. Sutton, S. (2017). Roadwork. Candlewick Press. Yoon, S. (2012). Do cows meow? Sterling Children’s Books.

6.  Facilitating Speech and Language in Minimally Verbal Children   259

Limit the Number of Target Stimuli For children who are minimally verbal, the number of target utterances introduced during a session should be limited to just a few (Strand, 2020). Follow a blocked practice schedule when introducing new targets by repeating the same target many times in a row before moving on to a different stimulus item. By limiting the number of stimulus items per session, the child has the opportunity to practice a small set multiple times to begin to establish volitional control and develop sensorimotor plans for producing those words. If five or six target utterances are chosen for a session, one or two specific utterances can be incorporated into each practice activity so as not to overwhelm the child by trying to practice too many new movement plans at once.

Using Scaffolding and Shaping Scaffolding and shaping are extremely beneficial during the treatment process, even with minimally verbal children. As a child gains sensorimotor control over a simplified production of a target utterance, the complexity of the target gradually can be increased. The sample script in Box 6–4 offers an example of using scaffolding to facilitate production of a CV word with a child who is minimally verbal.

Box 6–4.  Using Scaffolding From Isolated Vowel to Elicit CV Production Clinician:  Whose turn is it to blow the bubbles? Child:  (points to Mom) Clinician:  Okay, Mommy’s blowing bubbles! (Mom blows bubbles and child pops them) Who popped all those bubbles? Child:  (points to self) “eeee” [i] Clinician:  Wow! You popped a lot of bubbles. I like how you pointed to yourself and said, “Me.” Let’s practice the word “me” again. Close your lips and say, “me.” Child: [i] Clinician:  Great smiley lips, but we need to use the humming sound, “mmm.” Let’s do it together. Close your humming lips and say “me.” Clinician and Child together:  Clinician–“me,” Child — [i] Clinician:  You’re trying hard. We’ll practice our humming lips again. Time to blow more bubbles. (child blows bubbles) Who blows bubbles now? Child:  (points to self) “eeee” [i] Clinician:  Let’s practice “me” again. We’ll just say the last part, “ee.” Clinician and child together:  [i] Clinician:  Great, let’s do a few more — “ee.” Child:  [i, i, i, i] continues

260   Here’s How to Treat Childhood Apraxia of Speech

Box 6–4.  continued Clinician:  You did it just like me. Now let’s try a new way. Close your lips. Let’s see your humming lips. Child:  (closes lips) Clinician:  Yay, your lips are ready to go. Say [mi] (the /m/ model is prolonged). Clinician and Child together:  [mi] (Clinician applies a tactile cue to facilitate production of /m/) Clinician:  Yes! You made your humming sound — “me” (/m/ is prolonged; bubbles are offered for the Child to blow). Whoo hoo! So many bubbles that time! Now who gets to blow the bubbles? Child:  (points to self) [i] Clinician:  Woops. Let’s find that humming sound. (pretends to look around for the sound) Oh, there it is. Right on your lips! “Me.” (/m/ is prolonged) Clinician and Child together:  [mi, mi, mi] (using tactile cue) Clinician:  Fabulous humming lips! Time to blow some bubbles. Whoa! Who made all those big bubbles? Let’s make our humming lips together. . . . Clinician and Child together:  [mi] (no tactile cue, just simultaneous production) Clinician:  Great humming! Four more. (Clinician holds up four fingers) Clinician and Child together:  [mi mi] Child alone:  [mi mi] (Clinician miming) Clinician:  That was terrific. So many humming sounds. You can blow bubbles two times for all those great humming sounds!

Addressing Language Goals in Treatment Children with CAS frequently demonstrate significant expressive language challenges including limitations in the areas of syntax and morphology (Ekelman & Aram, 1983). Ekelman and Aram’s findings suggest that the mean length of utterance (MLU) of children with CAS was not a good indicator of the integrity of the syntactic or grammatical abilities of the children. Children with CAS exhibited omissions or incorrect productions of grammatical elements and pronouns that could not be attributed to limitations in sensorimotor speech planning or phonology. Lewis et al. (2004) found that many children with CAS exhibited significant receptive as well as expressive language deficits, although expressive language typically lagged behind receptive language. An important role of the SLP is to assess, identify, and prioritize all the child’s communicative needs and determine how and when to address each deficit area.

Expand Vocabulary Variety to Facilitate Phrase Production A careful analysis of a child’s expressive vocabulary will help provide ideas of ways that early phrases can be facilitated. It also may uncover holes in the child’s vocabulary that reduce the

6.  Facilitating Speech and Language in Minimally Verbal Children   261

opportunities for combining words to form phrases. For instance, a child whose vocabulary consists primarily of object labels will have difficulty formulating meaningful phrases. Some ready-made picture sets for apraxia and articulation will hinder the expansion of vocabulary from a wider range of parts of speech. Vocabulary will need to be expanded beyond labels to include pronouns, verbs, adjectives, adverbs, prepositions, conjunctions, articles, and interjections.

Use Carrier Phrases to Expand Utterances The use of carrier phrases is a common treatment strategy in apraxia intervention (Velleman, 2003). When teaching carrier phrases, the phrase shell remains the same, with the exception of the target word(s), which changes. Considerations when choosing carrier phrases include the following: • Initially the stable portion of the carrier phrase should be relatively easy for the child to produce (e.g., “Hi ___;” “more ___;” “no ___;” “___ in”) so that the child is not challenged on the target word and the carrier phrase simultaneously. • The carrier phrase should be functional so there are opportunities to practice the phrase in a variety of settings and within the context of a variety of activities. • As children advance, the complexity of the carrier phrase can be more challenging:   • Target phoneme /s/. “S Sit on a __________.” (sseat, sock, seven, circle)   • Target phoneme /dʒ /. “I jumped over a __________.” (jjet, jelly bean, giant, giraffe) Table 6–3 lists several sample carrier phrases with play activities that could be used to practice these phrases and short sentences in a session.

Facilitate Early Semantic Relations An additional benefit of moving quickly into production of phrases and sentences is that it enables the child to begin to develop more complex syntactic structures. Developing more complex syntax is essential because the clarity of a speaker’s message is not based solely on the integrity of the articulation but also on the complexity of the language. For instance, a child may produce the word “ball.” Out of context, it is difficult for the listener to interpret the meaning of the message. The child may be trying to request a ball, show someone a ball, indicate that Dad possesses a ball, or request assistance in finding a ball that has been lost. Unless more linguistic information is provided, the interpretation of the message can be understood only in context. Children combine words in a variety of ways that Brown (1973) described as “minimal two-term relations” (p. 173) that are prevalent in Stage I (MLU